197610252-4-11-2023-31-AS-TSMH-CQSR8H-20230411124757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610252
Report Date: 04/11/2023
Date Signed: 04/11/2023 12:48:02 PM

Document Has Been Signed on 04/11/2023 12:48 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:	FORBES HOME		FACILITY NUMBER:	197610252
ADMINISTRATOR:	ANDRES, CHARMILEY E.		FACILITY TYPE:	735
ADDRESS:	9608 FORBES AVE.		TELEPHONE:	(626) 926-7186
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 0	DATE:	04/11/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Charmiley Andres		TIME COMPLETED:	12:50 PM

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At 9:25 am Licensing Program Analyst (LPA) Tihesha Smith conducted an announced pre-licensing visit with administrator. Identification of the Applicant/administrator was verified by CA driver’s license.

The facility has a capacity of four (4). Application received for 4-bedridden clients.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. The facility is a single-story building.

Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The common areas (kitchen, living room, and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture.

The facility has a variety of adequate perishable and non-perishable food supply. Appliances in the kitchen appeared to be functional. The sharps are stored and locked in drawer in kitchen and under kitchen sink. Kitchen cleaning supplies, laundry detergents, and other toxins are stored and locked under the kitchen sink.

Laundry room located in garage. Washer and dryer observed to be in good repair.

There is one (1) fire extinguisher: located in kitchen area attached to wall. Fire extinguisher observed to be fully charged. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested, and observed to be operational at approximately 10:05 am.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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: FORBES HOME	FACILITY NUMBER: 197610252
	VISIT DATE: 04/11/2023

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(Cont from 809)

There is a functioning telephone/landline on the premises. An emergency exit plan/sketch is posted next to fire extinguisher with other posting requirements on opposite wall.

There are three (3) bathrooms in the facility: The hot water was tested for the bathrooms and measured at 118.0 °F for all bathrooms. The bathrooms have non-skid mats, trash cans with lids and functional grab bars.

There are four (4) client bedrooms: no room is designated for staff use. Client bedrooms were observed to be appropriately furnished with a bed, nightstand, and chair.

Extra linen is stored in cabinet in living room next to bathroom #2.

Medications and first aid kit are stored in locked upper kitchen cabinet. Client and staff records stored in locked cabinet in dining area.

There is a patio table, chairs, and umbrella for clients use in the backyard. There is no body of water at the facility.

Component III was conducted with the administrator and administrator confirmed understanding of Title 22.

Facility appears to be clean and in good repair. At time of visit this facility is ready to be licensed .

This report will be forwarded to the Centralized Application Bureau (CAB).

Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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