197610316-1-12-2023-31-AS-TCAS-CMZQKR-20230112111447

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610316
Report Date: 01/12/2023
Date Signed: 01/12/2023 11:16:36 AM

Document Has Been Signed on 01/12/2023 11:16 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HERON RESIDENTIAL CARE		FACILITY NUMBER:	197610316
ADMINISTRATOR:	OSIO, JONAH REY G.		FACILITY TYPE:	735
ADDRESS:	14107 HERRON ST.		TELEPHONE:	(818) 516-6016
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	4	CENSUS: 0	DATE:	01/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Jonah Osio & Natasha Rovira		TIME COMPLETED:	11:30 AM

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a PRE-LICENSING visit to the above address 14107 Herron Street, Sylmar, CA 91342. LPA met with Administrator Jonah Osio and Natasha Rovira. The inspection included, fire safety, personal accommodations, building and grounds, furniture/equipment, food service, and medication procedures. Fire Inspection was approved on September 30, 2022 which met fire department requirements for (2) shared and (2) private rooms. Facility sketch, emergency disaster plan, complaint procedures, personal rights, emergency exit plan, and other required Licensing were visibly posted. COVID signs, visitor book, and hand washing station observed at the front entrance.

The physical plant was toured inside and out with Jonah and Natasha. The facility is a one level home, with (2) shared and (2) private bedrooms for staff. Food supply was inspected and observed, and storage areas, cabinets, pantries, cupboards counters, and refrigerator were clean and appropriate for food preparation. Knives and medication were stored in cabinets located in the kitchen area. Appliances were clean and functional, and utensils, plates, and cups were in good repair. Cleaning supplies, poisons, toxins and chemicals were locked and stored in the laundry and pantry room. There was enough supply of linens and towels, which were stored in a cabinet located in the hallway. Hygiene products were also available, and stored in the bathroom. LPA observed at least (30) day supply of PPE.

The common areas included the dining, living, bathroom, and bedrooms were clean in good repair. Doors and passageways were clear and unobstructed. Walls, ceilings, floors, window screens and all other rooms were clean, in good repair, and appropriately furnished. Resident rooms observed to have a mattress with pad, sheets, pillow, bedspread, dresser, closet space, and chair. Bathrooms were clean had functional fixtures, with soap and towels, non-skid mats, grab bars and hand washing signs were posted.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

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: HERON RESIDENTIAL CARE	FACILITY NUMBER: 197610316
	VISIT DATE: 01/12/2023

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The water temperature measured at 105.8 degrees Fahrenheit. The back yard is completely fenced with a gate easily accessible and unlocked. There are no swimming pools or other bodies of water, no visible hazards around the surrounding grounds. Patio furniture with covering available for resident's use.

Smoke detectors and carbon monoxide were hardwired and operating correctly. Fire extinguisher is fully charged. Telephone installation was completed. First aid kit inspected. Staff and client files will be stored a locked cabinet, located in the dining room area.

COMP III was completed during the visit and Infection Control plan was reviewed and discussed.

Exit interview conducted and copy of report provided to Administrator Jonah.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday Cabiness	TELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:	DATE: 01/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/12/2023

LIC809 (FAS) - (06/04)

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