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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610310
Report Date: 02/10/2023
Date Signed: 02/10/2023 12:16:25 PM

Document Has Been Signed on 02/10/2023 12:16 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:HODGES HOMES INC.FACILITY NUMBER:
197610310
ADMINISTRATOR:KING, MARLONFACILITY TYPE:
735
ADDRESS:37137 CANNON CTTELEPHONE:
(661) 860-4425
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 4CENSUS: 0DATE:
02/10/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Marlon King, Administrator TIME COMPLETED:
12:40 PM
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At 10:20am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an announced Pre-licensing Inspection. Upon arrival LPA met with Administrator, Marlon King. This is an application for Adult Residential Facility and has the Fire Clearance had been approved on 08/23/22 for a total capacity of four (4) ambulatory clients. The facility is a two-story home with four (4) bedrooms and two (2½ ) bathrooms.

Common Area: LPA observed the living room and furniture to be clean and in good repair. Living area has a fireplace with appropriate covering. The facility maintains a comfortable temperature of 70 degrees F and has a functional air conditioner. No firearms observed or will be maintained on the premises. The smoke alarm and carbon monoxide detector were operational and tested at 11:00 a.m. The fire extinguisher was observed to be with a full charge and was last serviced on 06/28/2022. Facility will always maintain a cellphone and a land line in the facility for clients use.

Kitchen/Dinning Area: LPA observed the kitchen area to be in good repair and sanitary. LPA observed a startup fully of food as well as emergency food. Sharps and medications were observed to be locked and inaccessible to residents. Trash can contain a tight-fitting lid. Appropriate plates and cups were observed. Kitchen chemicals will be stored and kept locked underneath the kitchen sink. LPA observed the dining area to be clean and in good repair. Activities were observed in the dining room area. First aid kit was observed with all the appropriate requirements.

Bedrooms: Facility has four (4) bedrooms of which all will be used for clients. All bedrooms were toured and observed with appropriate furniture and bedding. Trash cans in bedrooms will contain tight fitting lids to prevent cross contamination. This facility will have an awake staff.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2023
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: HODGES HOMES INC.
FACILITY NUMBER: 197610310
VISIT DATE: 02/10/2023
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Bathrooms: Facility has two (2) bathrooms designated for client’s use. Bathrooms were toured and the hot water was tested and measured at 120 degrees F. LPA observed sufficient towels and wash cloths for clients .

Garage: Facility has a garage that is accessible through the laundry area. Garage will be used for storage and chemicals and will be kept locked and inaccessible to clients in care

Outside: 10:55 a.m. LPA observed appropriate outdoor furniture with a shaded area for clients. There are no bodies of water.

Pre-Licensing Self-Certification checklist was discussed with administrator. LPA discussed preplacement staffing, training, customer service, inspection authority, reporting requirements (mandated reporter), records, citations, criminal record clearance, civil penalties, labor law, activities, expectation is to follow all rules and regulations. No deficiencies were observed.

Once component III is completed, this report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

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

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023
LIC809 (FAS) - (06/04)
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