197610399-9-21-2023-31-AS-APAA-CVVPLA-20230921112425

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610399
Report Date: 09/21/2023
Date Signed: 09/21/2023 11:25:18 AM

Document Has Been Signed on 09/21/2023 11:25 AM - 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:	EMPOWER RESIDENTIAL WELLNESS CENTER LLC		FACILITY NUMBER:	197610399
ADMINISTRATOR:	DAHLMANN, MARIA		FACILITY TYPE:	772
ADDRESS:	22119 BASSETT STREET		TELEPHONE:	(818) 209-5011
CITY:	CONOGA PARK	STATE: CA	ZIP CODE:	91303
CAPACITY: 6		CENSUS: 0	DATE:	09/21/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Maria Dahlmann, Administrator		TIME COMPLETED:	11:50 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	Licensing Program Analysts (LPAs) Angela Panushkina and Christopher Alemoh conducted a Pre-Licensing Inspection with Licensee/ Owner Tom Mcnulty and Program Directors/Administrators Maria Dahlmann. An Application to operate a Social Rehabilitation Facility, Short-Term Crisis Residential Treatment Program was received by Community Care Licensing (CCL) on 08/23/2023. A fire clearance was approved on 08/01/2023 for a maximum capacity of six (6) ambulatory adults. A tour of the physical plant was initiated at 11:10am and the following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Fire Extinguisher was last serviced on 05/07/2023 BEDROOMS: There are six (6) bedrooms designated for client use. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space. BATHROOMS: There are four (4) bathrooms. LPAs observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water delivered in the client bathrooms measured at 116.8°F COMMON AREAS: The facility maintains a comfortable temperature at 71°F. These included a living room furniture, a television, tables and chairs and a dining area. The Common areas are furnished with adequate furniture to accommodate a maximum capacity of six. There were no visible immediate hazards. Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

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: EMPOWER RESIDENTIAL WELLNESS CENTER LLC	FACILITY NUMBER: 197610399
	VISIT DATE: 09/21/2023

NARRATIVE

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LAUNDRY ROOM: The laundry room is located in the locked office. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

MEDICATION ROOM: The medication will be kept in a locked cabinet located in a staff office.

OFFICE, STAFF AND THERAPY/TREATMENT AREAS, GUEST ROOM: There is one office space and that will be used for administrative duties and individual therapy. Group Therapy will be conducted in the common areas.

SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. LPAs discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water.

During the Pre-Licensing visit Component III interview completed with the Administrator. In addition, LPAs informed the Administrator that they cannot under any circumstances do detox treatment at this facility.

Pursuant to Title 22, the facility is compliant to regulation, and ready for licensure. This report will be forwarded to the Centralized Application Bureau (CAB). The applicant will be notified by the CAB Analyst when their license is approved.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2023

LIC809 (FAS) - (06/04)

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