197610463-12-1-2023-31-AS-NRED-CY4UF8-20231201143218

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610463
Report Date: 12/01/2023
Date Signed: 12/01/2023 02:32:28 PM

Document Has Been Signed on 12/01/2023 02:32 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:	GOOD SAMARITAN HOME CARE LLC		FACILITY NUMBER:	197610463
ADMINISTRATOR:	VILLON, LEILA G.		FACILITY TYPE:	735
ADDRESS:	20746 COMMUNITY STREET		TELEPHONE:	(818) 914-1472
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 4		CENSUS: 3	DATE:	12/01/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Leila Villon		TIME COMPLETED:	02:35 PM

NARRATIVE

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At approximately 10:30 a.m. on 12/01/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted an announced prelicensing inspection. LPA met with the applicant and disclosed the reason for the visit.

Today’s prelicensing visit was conducted for a Change of Ownership (CHOW) with clients in care. The previous facility, Regal Home Care Corporation (#197607169) was last visited on 10/26/2022 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) clients. The master bedroom is approved as non-ambulatory, and Bedrooms #1, #2, and #3 are approved for ambulatory clients only.

LPA and the applicant reviewed the Compliance and Regulatory Enforcement (CARE) Tools at 10:30 a.m.

LPA and the applicant reviewed Component III at 11:30 a.m.

LPA and applicant toured the facility inside and out at 12:00 p.m. No immediate health and safety hazards were observed during this visit.

At the main entrance, LPA observed a maintained front yard. An infectious disease screening station was placed at the entrance containing visitor log, digital thermometer, gloves, masks, hand sanitizer, and cleaning wipes. LPA was screened upon entry.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:10 p.m. LPA measured the room temperature to be 71.0 degrees Fahrenheit. Activities, puzzles, and board games were observed in the living room. A client was observed sitting in the living room. Furniture was maintained in good condition. The hallways contained night lights and motion sensing lights. Additional linens and towels were stored in the hallway closet.

LPA observed adequate supplies of perishable foods, non-perishable foods, and emergency food and water in the pantries, refrigerator and freezer. The stove hood was clean. Appliances were operable and in good

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOOD SAMARITAN HOME CARE LLC	FACILITY NUMBER: 197610463
	VISIT DATE: 12/01/2023

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condition. Sharps, disinfectants, and cleaning supplies were locked below the sink. Medications and client records were locked above the counter top. Two first aid kits were locked below the counter top. At 12:15 p.m. LPA and applicant reviewed the first aid kits to be complete with manual, bandages, gauze, tweezers, scissors, and digital thermometer. Additional PPE supplies such as masks and gowns were stored near the kitchen. All required postings were observed in the kitchen area.

LPA observed a covered and shaded patio area in the rear of the facility. The back yard was accessible through the kitchen exit. The patio contained furniture in good condition. A gas grill and fruit trees was also located in the back yard. All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked. At approximately 12:20 p.m. smoke and carbon monoxide detectors were tested and operational. At approximately 12:25 p.m. LPA observed two (02) fully charged fire extinguishers in the kitchen and at the front entrance.

A washing machine and dryer were located in the laundry room near the front entrance. Both were in working order. Detergents were locked in the garage. The garage was locked and also contained incontinence supplies, and extra refrigerator, and additional PPE.

The facility has 4 bedrooms. Bedroom #3 is designated as a staff room. The staff room was locked and free of hazards. Bedroom #1 and Bedroom #2 are private rooms, and the master bedroom is a shared room. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition.

The facility has 2 bathrooms. 1 bathroom is private in the master bedroom, and 1 is shared. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 12:30 p.m. LPA measured the water temperature to be 111.3 degrees Fahrenheit.

At 1:15 p.m. LPA reviewed staff and client records. At approximately 2:00 p.m. LPA conducted a medication review.

During today's inspection, the facility was in compliance with Title 22 regulations. Pre-licensing is complete and this facility has no deficiencies.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 12/01/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/01/2023

LIC809 (FAS) - (06/04)

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