197610247-7-22-2024-31-AS-HRAI-D7EREL-20240722125744

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610247
Report Date: 07/22/2024
Date Signed: 07/22/2024 12:58:18 PM

Document Has Been Signed on 07/22/2024 12:58 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PHIBA HOME		FACILITY NUMBER:	197610247
ADMINISTRATOR/ DIRECTOR:	KAWOOYA, DAVID		FACILITY TYPE:	735
ADDRESS:	20112 LANARK ST		TELEPHONE:	(818) 617-0594
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 4		CENSUS: 4	DATE:	07/22/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:55 AM
MET WITH:	Rita Nabukenya, Staff		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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At 09:55 AM, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced annual inspection. LPA met with staff. Staff informed LPA that the Administrator is out of the country. Staff contacted the Administrator via telephone and LPA disclosed the reason for the visit. The Administrator confirmed that staff can sign today’s report in their absence. LPA and staff toured the facility inside and out and the following was observed.

The facility is a single-story building with six (06) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for four (04) ambulatory clients.

Kitchen: At 10:20 AM, LPA observed the kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Stove burners were tested and operational. Knives were stored in a locked drawer in the kitchen. Cleaning supplies were observed lock underneath the kitchen sink.

Bedrooms: 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.

Bathrooms: The facility has three (3) bathrooms. One (1) bathroom is private, and two (2) are 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 10:35 AM, LPA measured the water temperature in the shared bathroom to be 119.1 degrees Fahrenheit. No cleaning supplies are being stored in the three bathrooms.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PHIBA HOME	FACILITY NUMBER: 197610247
	VISIT DATE: 07/22/2024

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Common Areas: Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:40 AM, LPA measured the room temperature to be 76 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.

Surrounding Grounds: At 10:55 AM, LPA observed that entry/exits were free of obstruction. Facility has a large backyard area. The outdoor area was free of hazards. LPA observed a patio which contained furniture in good condition, a grill, exercise equipment, and a gardened area. An outdoor storage shed was locked.

Smoke detectors/carbon monoxide. At 11:00 AM, carbon monoxide and smoke detectors were tested and operational. At 11:02 AM, LPA observed a newly purchased (07/22/2024) fire extinguisher in the dinning area.

Garage: LPA observed that the garage was locked and contained an additional freezer and client supplies.

Between 11:30 AM to 12:30 PM, LPA reviewed records of two (2) clients and two (2) staff. Client and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:	DATE: 07/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/22/2024

LIC809 (FAS) - (06/04)

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