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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610391
Report Date: 11/03/2024
Date Signed: 11/03/2024 12:06:43 PM

Document Has Been Signed on 11/03/2024 12:06 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:J6 ADULT HOMEFACILITY NUMBER:
197610391
ADMINISTRATOR/
DIRECTOR:
NARAJOS, EARLYNNFACILITY TYPE:
735
ADDRESS:1151 WEST AVENUE J6TELEPHONE:
(818) 859-3796
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 4CENSUS: 0DATE:
11/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:16 AM
MET WITH:Earlynn Narajos - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:02 PM
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A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Administrator Earlynn Narajos and explained the reason for the visit. This will be a North Los Angeles Regional Center (NLARC) vendored facility Level III.

A tour of the physical plant was conducted at 9:40 AM and the following was noted:

The main door is the only entrance being utilized at this facility. Screening area is located immediately after entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan.

Hand washing, coughing etiquette, physical distancing were posted in the bathroom and board . 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) private client bedrooms and two (2) bathrooms. There is no body water in the facility. The facility is fire cleared for four (4) non-ambulatory residents.

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 was measured at 112.3°F.

(continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 11/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/03/2024
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: J6 ADULT HOME
FACILITY NUMBER: 197610391
VISIT DATE: 11/03/2024
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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 obstructions during today's visit.
Living and dining and Activity/Office room 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 cabinet in the garage.
Food. There are no client at this time.
Temperature of facility wall thermostat is observed to be within the required range.
Fire extinguisher: There is a fire extinguisher in the facility located in the kitchen. Extinguisher was observed to be operable and last check on 03/13/24. Smoke alarms hardwired and interconnected, tested and observed to be operable. There is a carbon monoxide installed at the facility.

Garage is attached to the house, but has no access from the inside. Garage is being used as a storage for emergency food and equipment (Generator) and other supplies. Cleaning solutions and laundry detergents are observed kept in the locked cabinet in the kitchen. Laundry area is located adjacent to the kitchen. There is an empty shed at the backyard observed to be locked during visit.



Medication will be kept in a secured cabinet in a kitchen. There is a complete First Aid kit kept in the medication cabinet.

Staff & Client records. There are no clients at this time.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2024
LIC809 (FAS) - (06/04)
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