197610335-2-9-2024-31-AS-NRED-D2AVH6-20240209152637

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610335
Report Date: 02/09/2024
Date Signed: 02/09/2024 03:26:44 PM

Document Has Been Signed on 02/09/2024 03:26 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:	A PLACE FOR US		FACILITY NUMBER:	197610335
ADMINISTRATOR:	PASCASIO, JOEY		FACILITY TYPE:	735
ADDRESS:	6639 CAPISTRANO AVE		TELEPHONE:	(818) 854-5448
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY: 4		CENSUS: 4	DATE:	02/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Joey Pascasio		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

At 12:20 p.m. on 02/09/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit. LPA and administrator toured the facility inside and out at 12:50 p.m.

A file review was conducted prior to the visit.

The facility was last visited on 01/17/2023 for a prelicensing inspection. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen. garage, common areas, and outdoor areas. It has an approved fire clearance for four (04) residents, of which three (03) may be nonambulatory in Bedrooms #1, #2, and #3, and one (01) ambulatory in Bedroom #4.

At the main entrance, LPA observed postings for the administrator certificate, facility license, facility sketch, confidential complaint contacts, personal rights, house rules, staff list, resident list, emergency contacts, grievance policy, and COVID precautions. A screening station was present near the front and contained a digital thermometer, masks, sanitizer, and a visitor log.

LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator, freezer, and pantry. The stove hood was clean. Appliances were in good condition. A weekly menu was posted on the refrigerator. Sharps were locked below the sink. Medications were locked above the counter top.

The garage was locked and contained an operational washer and dryer, emergency water, locked detergents and cleaning supplies, and an extra refrigerator.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 1:00 p.m. LPA measured the room temperature to be 72.0 degrees Fahrenheit. The living room contained a television, video game console, and furniture in good repair. A fireplace was turned off and appropriately grated. A linen closet at the end of the hallway contained adequate amounts of fresh linens and towels.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

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

FACILITY NAME: A PLACE FOR US	FACILITY NUMBER: 197610335
	VISIT DATE: 02/09/2024

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

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition and a gas grill. The lawn was maintained.

All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked with self-closing latches. At 1:05 p.m. the house telephone was called and verified to be operational. At approximately 1:15 p.m., smoke and carbon monoxide detectors were tested and operational. At approximately 1:20 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 01/05/2024.

The facility has four (04) bedrooms. One (01) bedroom is designated as a staff room. The staff room was locked and inaccessible. All client bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

The facility has two (02) bathrooms. 1 bathroom is private, and 1 is shared. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 2:00 p.m. LPA measured the water temperature in the shared bathroom to be 105.8 degrees Fahrenheit.

LPA reviewed personnel and client files at 2:15 p.m.

During today's inspection, the facility was in compliance with Title 22 regulations.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2