197610316-1-21-2024-31-AS-JGTN-CZPVHJ-20240121152713

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610316
Report Date: 01/21/2024
Date Signed: 01/21/2024 03:27:38 PM

Document Has Been Signed on 01/21/2024 03:27 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
WOODLAND HILLS S.ASC, 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: 1	DATE:	01/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:26 PM
MET WITH:	Jonah Rey Osio - Administrator		TIME COMPLETED:	03:30 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	A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Jonah Rey Osio. This is a North Los Angeles Regional Center vendored facility level 3. A tour of the physical plant was conducted at 12:39 PM and the following was noted: The only entrance being utilized is the main front door, there is a sign at the main door that everyone entering at the facility must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. Facility has four (4) bedrooms and three (3) bathrooms. Two (2) bedrooms and (2) bathrooms are designated for staff use. There is no body of water in the facility. Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels. Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at 106.7°F and within the required range. (continued to LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HERON RESIDENTIAL CARE	FACILITY NUMBER: 197610316
	VISIT DATE: 01/21/2024

NARRATIVE

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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living, dining and family rooms furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the garage. Knives and sharps were kept in a locked drawer.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat was set 73.0°F and observed to be within the required range.
Fire extinguisher. There are (2) fire extinguisher in the facility: one (1) in the kitchen and one (1) in the living room. Extinguishers were observed to be operable and last bought on 03/23/23. Dual smoke/carbon monoxide alarms are hardwired and interconnected, tested and observed to be operational. The garage is currently being used as frozen and emergency food, other supplies and used equipment storage and Laundry area. Laundry detergents and other cleaning agents and toxins are kept locked in the cabinet in the laundry area inside the garage. Medication was observed to be inaccessible and stored in a secured medication cabinet in the kitchen. There is a complete First Aid kit in the medication cabinet. There are two (2) sheds in the backyard being used as tool and barbecue shed. Both shed are observed to be locked.

Client records. Client record was reviewed. Client record appeared to be complete and current. Staff records were also reviewed. Two (2) staff records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 01/15/23. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2024

LIC809 (FAS) - (06/04)

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