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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610247
Report Date: 04/07/2025
Date Signed: 04/07/2025 11:37:21 AM

Document Has Been Signed on 04/07/2025 11:37 AM - 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 HOMEFACILITY NUMBER:
197610247
ADMINISTRATOR/
DIRECTOR:		AMANYA, JACOBFACILITY TYPE:
735
ADDRESS:20112 LANARK STTELEPHONE:
(818) 626-9296
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 4CENSUS: 4DATE:
04/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:03 AM
MET WITH:Rita Nabukenya - Caregiver/DSPTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 4/7/2025 at 9:00am Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a required Annual Inspection. Upon arrival LPA was greeted by the Caregiver/DSP Rita Nabukenya, who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. LPA Khurshudyan reviewed the required postings on a wall throughout the facility. The facility Administrator Jacob Amanya arrived at approximately 10:15am.The inspection tool was used to complete today's visit.

At 10:15am. LPA with the help of the caregiver began a physical plant tour of the facility and the following was observed: This is a single-story building with six (6) bedrooms, three (3) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for four (4) clients. Facility is operating level 3 clients.

Kitchen: LPA observed a seven-day supply of non-perishable food, and a two-day supply of perishable food properly stored and labeled. Facility stores knives and sharps inside kitchen cabinet that is always locked and under supervision. Emergency supply of food / water was stored inside the pantry. LPA observed fully charged one (1) fire extinguisher located in the kitchen with a service date 7/22/2024. A weekly menu was also available.


Common Areas: These include living and dining areas. LPA observed dining, living areas clean and clear of clutter. Furniture is generally new and in a good repair. Dining and living room furniture sits the capacity of the facility. Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:20am. LPA measured the room temperature to be 74 degrees Fahrenheit. There is a linen closet in the hallway with an adequate supply of fresh linens ready to use. No obstructions and or tripping hazards throughout the facility. Facility has landline, LPA checked it was operational. Continue on LIC809-C
NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/07/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: 04/07/2025
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LPA observed a fireplace in the living room gated with furniture and got informed that the fireplace is nonoperational. There is a television and various activities, games, board games, art supply available for clients to use.

Bedrooms: There are six (6) bedrooms in the facility, of which four (4) are designated for clients use and two (2) for staff use. All bedrooms are for private use. LPA observed bedrooms to be properly furnished with beds, linens, nightstands, chairs, drawers, closets, and adequate lighting. All bedrooms appeared organized and clean.

Bathroom: There are three bathrooms in the facility. The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. Hot water temperature was taken in two (2) bathrooms at approximately 10:10am measured 105.7 degrees Fahrenheit. LPA also observed required signs on the bathroom walls and non-skid mats inside the showers.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by a staff at 10:30am and were observed operational.

Garage: LPA observed the garage is attached to the facility and is currently being used as a storage for PPE supplies and for other tools.

Laundry Room: Functioning washer and dryer located in a hallway next to bedrooms #1 and #2. Disinfectants, laundry detergents and hygiene supplies were stored and inaccessible in locked cabinet inside the laundry room.

Backyard: LPA observed sufficient yard space and fenced backyard. Appropriate outdoor furniture, with covered shaded area available for clients to rest. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. The facility does not have a swimming pool or body of water.

Staff/Client File review: Facility records are kept inside the locked storage next to the main entrance. At 10:10am -11:10am LPA conducted records review of four (4) staff files and four (4) out four (4) clients records. Files were complete and updated.

Continue on LIC809-C

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC809 (FAS) - (06/04)
Page: 3 of 4
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: 04/07/2025
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Medications: At approximately 10:45am. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). LPA observed centrally stored medication, and First Aid kit locked in the commercial cabinet and inaccessible to clients in care. LPA observed First-aid kit is complete and has new manual. PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care. Facility operates with two (2) shifts and has two / three staff members for each shift.

An emergency exit plan/sketch is posted on the wall along with other posting requirements.

LPA collected LIC500, LIC9020 and Administrator's certificate.

No deficiency cited on today’s visit. Exit interview conducted. Copy of this report provided.

NAME OF LICENSING PROGRAM MANAGER: Nichelle Gillyard
NAME OF LICENSING PROGRAM ANALYST: Perchui Khurshudyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/07/2025
LIC809 (FAS) - (06/04)
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