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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610335
Report Date: 12/11/2024
Date Signed: 12/11/2024 01:15:23 PM

Document Has Been Signed on 12/11/2024 01:15 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 USFACILITY NUMBER:
197610335
ADMINISTRATOR/
DIRECTOR:		PASCASIO, JOEYFACILITY TYPE:
735
ADDRESS:6639 CAPISTRANO AVETELEPHONE:
(818) 854-5448
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 4CENSUS: 4DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:35 AM
MET WITH:Joan ComerTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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At 9:35 a.m. on 12/11/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit. Staff called the licensee at approximately 9:45 a.m. to disclose the reason for the visit.

A file review was conducted prior to today’s visit.

The facility was last visited on 02/09/2024 for an annual visit. 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, emergency disaster plan, grievance policy, and COVID precautions. A screening station was present near the front and contained a digital thermometer, masks, and a visitor log.

Walls, floors, windows, screens, and blinds were clean and in good repair. 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. At 9:50 a.m. the house telephone was called and deemed operational. At 10:00 a.m., LPA measured the room temperature to be 68.0 degrees Fahrenheit. At 10:05 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 01/05/2024.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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: A PLACE FOR US
FACILITY NUMBER: 197610335
VISIT DATE: 12/11/2024
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LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator, freezer, and pantry. The kitchen refrigerator and freezer temperatures were measured to be 40 degrees and 0 degrees Fahrenheit, respectively. 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. A medication review was conducted at 10:15 a.m. All doses of medications were properly administered and documented.

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

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. Four (04) out of four (04) exits had auditory alarms which were on and functioning. At approximately 10:30 a.m., smoke and carbon monoxide detectors were tested and operational.

The facility has four (04) bedrooms. One (01) bedroom is designated as a staff room. The staff room was locked and free of hazards. 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 1:00 p.m. LPA measured the water temperature in the shared bathroom to be 98.2 degrees Fahrenheit. Staff adjusted the hot water heater after the measurement. A note of Technical Violation is issued for the water temperature.

At 11:00 a.m. LPA reviewed staff and resident files. All files were complete and available for audit.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health or safety hazards were observed.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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