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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610247
Report Date: 11/17/2022
Date Signed: 11/17/2022 02:49:45 PM

Document Has Been Signed on 11/17/2022 02:49 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PHIBA HOMEFACILITY NUMBER:
197610247
ADMINISTRATOR:KAWOOYA, DAVIDFACILITY TYPE:
735
ADDRESS:20112 LANARK STTELEPHONE:
(818) 617-0594
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 4CENSUS: 4DATE:
11/17/2022
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
11:45 AM
MET WITH:Jovan SsemalkulaTIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Random visit and inspection of the facility. LPA met with staff, Jovan Ssemalkula and explained the reason for the visit.

At approximately 11:45am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are hardwired and interconnected. There is carbon monoxide detector, located in the hallway, by resident rooms that functions properly. The internal temperature of the facility is maintained at 73 degrees. The fire extinguisher is located in the kitchen. The charge date is 6/3/2021.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Cleaning supplies were observed lock underneath the kitchen sink.

Bedrooms: There were four (4) bedrooms designated for residents' use. All four rooms are for private use by the residents. They were were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are three (3) bathrooms designated for residents' use. All three bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 114 degrees Fahrenheit. No cleaning supplies are being stored in the three bathrooms.

Common Areas: These included the living room and dining area. The common areas were properly furnished with couches, television and a table. There is a fireplace with a screen that is inactive. No tools were present. The dining room has a large dining room table to accommodate six (6).
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/17/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PHIBA HOME
FACILITY NUMBER: 197610247
VISIT DATE: 11/17/2022
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Surrounding Grounds: Entry/exits were free of obstruction. Facility has a large backyard area. The outdoor area was free of hazards. The laundry area is located at the hallway, between the resident rooms. There was no cleaning supplies or detergent observed.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medications are maintained in the hallway closet. It was observed locked and inaccessible. Medication Records were reviewed for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted. A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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