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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610247
Report Date: 12/28/2023
Date Signed: 12/28/2023 03:26:39 PM

Document Has Been Signed on 12/28/2023 03:26 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
WOODLAND HILLS S.ASC, 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:
12/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:45 PM
MET WITH:Rita NabukenyaTIME COMPLETED:
03:30 PM
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At 12:45 p.m. on 12/28/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. Staff called the licensee at approximately 1:00 p.m. The licensee confirmed that staff can sign today’s report in his absence. LPA and staff toured the facility inside and out at 1:00 p.m.

The facility was last visited on 11/17/2022 for an annual inspection. It is a single story building with six (06) bedrooms, two (02) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for four (04) ambulatory clients.

At the main entrance, LPA observed a maintained front yard. Postings observed inside included the emergency disaster plan, facility license, grievance procedure, personal rights, confidential complaint contacts, and activity schedule. A screening station at the front consisted of a digital thermometer, masks, sanitizer, and gloves.

The facility has six (06) bedrooms. Two (02) bedrooms are designated as a staff rooms. The staff rooms were locked and free of hazards. All bedrooms contained a chair, lamp or flashlight, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 1:10 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. Activities, board games, television, and reading material were observed in the office and living room. An inactive fireplace was also in the living room. Medications and confidential files were locked in a closet near the main entrance. A washing machine and dryer were located across from Bedroom #1. Both were in working order. Detergents were locked above the appliances.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PHIBA HOME
FACILITY NUMBER: 197610247
VISIT DATE: 12/28/2023
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The facility has 2 bathrooms. 1 bathroom is private, and 1 is shared. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid. The shared bathroom shower had non-skid strips on the floor. At approximately 1:15 p.m. LPA measured the water temperature in the shared bathroom to be 119.1 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator, freezer, and surplus freezer. A weekly menu was posted on the refrigerator. The stove hood was clean. Appliances were in good condition. Stove burners were tested and operational. Sharps and cleaning solutions were locked below the sink.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition, a grill, exercise equipment, and a gardened area. An outdoor storage shed was locked.

All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked with inward facing, self-closing latches. At approximately 1:40 p.m. the carbon monoxide detector was tested and operational. At approximately 1:45 p.m. the smoke detector was tested and operational. At approximately 1:55 p.m. LPA observed a fully charged fire extinguisher in the dining area. At 2:00 p.m. the house telephone was tested and functioning.

The garage was locked and contained an additional freezer and client supplies.

At 2:15 p.m. LPA conducted a record review of client and staff files.

During today's inspection, the facility was in compliance with Title 22 regulations.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
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