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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610399
Report Date: 11/14/2024
Date Signed: 11/14/2024 11:53:21 AM

Document Has Been Signed on 11/14/2024 11:53 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 LLCFACILITY NUMBER:
197610399
ADMINISTRATOR/
DIRECTOR:
DAHLMANN, MARIAFACILITY TYPE:
772
ADDRESS:22119 BASSETT STREETTELEPHONE:
(818) 209-5011
CITY:CONOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: 6DATE:
11/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Michele Clark, Program Director TIME VISIT/
INSPECTION COMPLETED:
12:20 PM
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At 09:00am, Licensing Program Analyst (LPA) Angela Panushkina arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA met with the Program Director and explained the reason for the visit.

LPA conducted a tour of the physical plant and observed the following:

Facility is licensed for capacity of six (6) Ambulatory clients. There are six (6) private bedrooms designated for clients’ use. All bedrooms are appropriately furnished and have appropriate lighting. Facility has awake staff at night. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. The hot water temperature measured at 114.9°F. Facility maintains a temperature of 73°F. LPA observed there to be sufficient stock of one-week perishable foods and two-day non-perishable foods. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. The facility has two (2) fire extinguishers located throughout the facility and were last serviced on 06/17/2024. Laundry, medications and the knives are located in a Medroom. The washer/dryer appear to be in good condition. All chemicals, detergents, sharps and medications are kept locked and inaccessible to clients in care. Smoke detectors and carbon monoxide monitors were tested at 11:30am and observed to be functional. At 11:50am, LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients.

Between 10:20am to 11:30pm, LPA reviewed records of six (6) client and three (3) staff. Client and staff records appeared to be complete and updated. LPA collected Certificate of Liability Insurance and LIC500.

No deficiency cited during today's visit.
Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 11/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/14/2024
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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