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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610351
Report Date: 02/16/2023
Date Signed: 02/16/2023 12:23:11 PM

Document Has Been Signed on 02/16/2023 12:23 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:GIG HOMESFACILITY NUMBER:
197610351
ADMINISTRATOR:JOHNSON, OLUWAROTIMIFACILITY TYPE:
735
ADDRESS:40035 CHALFONT CTTELEPHONE:
(310) 503-1777
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 0DATE:
02/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Foluke Ayoariyo and George AyoariyoTIME COMPLETED:
12:30 PM
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On 2/16/2023, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced Pre-Licensing visit to this facility and met with applicant Foluke Ayoariyo and George Ayoariyo. This is an initial application for an Adult Residential Facility. A fire clearance dated 12/20/2022 was received for four (4) ambulatory residents. The applicant stated the facility has been approved for four non-ambulatory residents. The issue has been referred to CAB and CAB will be contacting the Los Angeles County Fire Marshall, Randy Frantz to send a revised Fire Safety Inspection Request. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

LPA conducted the COMP III presentation from 9:20 am until 10:22 am.

Today’s site visit consisted of LPA touring the physical plant inside and outside. The tour began at 10:30 am and concluded at 11:00 am. LPA observed the following:

Living Room/Dining Room Combination – LPA observed a dining room table with chairs in the dining area. The living room is furnished with comfortable seating, games, and a television. The emergency exit plan/sketch is posted on the dining room wall with other posting requirements. The medications are centrally stored in a locked four drawer cabinet located in the dining room. The first aid kit is available.

Kitchen Area – The facility has a fire extinguisher with a date of purchase of 11/22/2022. There is a functioning telephone on the premises and the facility phone number is 661-208-8391. The knives and PPE supplies are locked in a kitchen cabinet. The facility contains a two-day supply of non-perishable food items and a seven-day supply of perishable food items. The facility PPE is locked in a kitchen cabinet. LPA observed the facility menu posted in the kitchen.

(CONT. on LIC809-C)
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/16/2023
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: GIG HOMES
FACILITY NUMBER: 197610351
VISIT DATE: 02/16/2023
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Bedrooms – there are four resident bedrooms which contain bed, linens, chest of drawers, lamp, night stand and a chair
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Bathrooms – There are three (3) bathrooms in the facility. Two bathrooms are located in resident rooms (Room One and Room Four). The third bathroom is used by staff and residents. The bathrooms contained wash your hands sign, hand soap, paper towels and covered trash cans. LPA tested the water temperature at 10:35 am. The water temperature was 110.0 degrees F.

Hallway Cabinets – Clean linens are stored in a hallway cabinet. The resident’s personal hygiene items are safely locked in the hallway cabinet.

Laundry Room/Facility Office –The laundry room and facility office are combined. The laundry detergent and cleaning solutions are locked in a cabinet. Resident and staff records are stored in a locked cabinet in the facility office.

Smoke/Carbon Monoxide Detectors- The smoke/carbon monoxide detectors were tested at 10:55 am and were operational.

Outdoor area – There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced and there are no bodies of water. The gate leading from the backyard to the front yard is not locked.

This report will be forwarded to the Centralized Application Bureau (CAB). The Applicant will be notified by the CAB Analyst when the facility license has been approved. Exit interview was conducted and a copy of the report was signed and given to the Applicant.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 02/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023
LIC809 (FAS) - (06/04)
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