197610260-8-25-2022-31-AS-NRED-CHMTMX-20220825145151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610260
Report Date: 08/25/2022
Date Signed: 08/25/2022 02:52:02 PM

Document Has Been Signed on 08/25/2022 02:52 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:	TELECARE OLIVE HOUSE		FACILITY NUMBER:	197610260
ADMINISTRATOR:	TBH		FACILITY TYPE:	772
ADDRESS:	14149 BUCHER AVE		TELEPHONE:	(925) 250-5288
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY: 16		CENSUS: 0	DATE:	08/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Robbie Kenobi		TIME COMPLETED:	03:03 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

At approximately 12:00 p.m. on 08/25/2022, Licensing Program Manager (LPM) Cassandra Harris conducted an announced prelicensing visit. LPM met with Administrator and disclosed the reason for the visit. At approximately 12:40 p.m. Licensing Program Analyst (LPA) Nicholas Reed joined the inspection. LPA, LPM, and Administrator toured the facility inside and out.

It is a two story facility with 9 bedrooms, 9 bathrooms, pantries, common areas, lactation room, medication room and outdoor areas. It has an approved fire clearance for 16 residents, of which 2 may be non-ambulatory. The facility uses surveillance cameras inside.

LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer and a digital visitor log. The visitor log tracked contact information, temperature, symptoms, and vaccination status. Postings included grievance procedures, personal rights, confidential complaint contacts, house rules, activity schedule, and facility menu. Walls, floors, ceilings, windows, and blinds were clean and in good repair. At approximately 12:30 p.m. LPM tested the smoke detectors to be operational. At 12:50 p.m. LPA measured the room temperature to be 75 degrees Fahrenheit. At 12:55 p.m. LPM tested the carbon monoxide detector to be operational, and LPA measured the water in a hallway bathroom to be 109 degrees Fahrenheit. Past the screening station were an intake office and a mud room. The mud room contained a shower and a Zapp machine for sanitation. Janitor closets with cleaning supplies on the first and second floor were locked. Extra linens, client lockers, activities, board games, and hygiene supplies were located in storage closets on the first and second floor. The facility has emergency water supplies and emergency food supplies in the first floor pantry. The pantry contained sufficient supplies of perishable and non-perishable food. The pantry also contained two refrigerators, two freezers, cooking tops, and a retherm unit. At 12:59 p.m. LPA measured a refrigerator and freezer temperatures to be 37.2 degrees Fahrenheit and -2.2 degrees Fahrenheit, respectively. Sharps were locked in a lockbox by the sink. The dining room outside of the pantry contained utensils, coffee machine, and snacks.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TELECARE OLIVE HOUSE	FACILITY NUMBER: 197610260
	VISIT DATE: 08/25/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

The facility has 9 bedrooms in total. 2 bedrooms on the first floor are private. 2 on the first floor and 5 on the second floor are shared bedrooms. Bedrooms had doors which could be opened from the outside in case of emergency. All bedrooms contained a chair, nightstand, emergency lighting, facility sketch with evacuation routes clearly labelled, storage, and beds with adequate beddings. All furnishings were clean and in good condition. Shared rooms contained beds which were at least 6 feet apart for social distance. All beds and bathrooms contained a pull cord for the call system. At 1:03 p.m. LPA tested the pull cords in Room 117. The light above the doorway signaled, and office computers were alerted. Administrator noted the staff will perform hourly checks on clients. Laundry machines are located on the first floor with locked cabinets for detergents. The facility has 9 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction signs, and grab bars near toilets and shower. Staff offices, medication room, lactation room, and bedrooms were on the second floor. The medication room contained a refrigerator and a locked medication cabinet with extra locked storage. The facility has two complete first aid kits. At 1:09 p.m. LPA observed a fully-charged fire extinguisher on the second floor which was last serviced on 07/22/2022. All emergency exit paths were free from obstructions. Exit doors were unlocked. Emergency Disaster Plan posted. The facility has fire sprinklers installed, and all smoke detectors are hardwired. The outdoor area was sanitary and free of hazards. Outdoor space included shaded furniture in good condition.

At 1:14 p.m. LPA, LPM, and Administrator confirmed the facility vehicle is in good working condition, operable, and has current registration and insurance.

At approximately 2:00 p.m. LPA and Administrator reviewed Component III.

Exit interview conducted. Copy of report issued.

Pre-Licensing will be complete upon approval of a food waiver.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2