197610463-12-6-2024-31-AS-PKHN-DBPSSD-20241206130748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610463
Report Date: 12/06/2024
Date Signed: 12/06/2024 01:10:18 PM

Document Has Been Signed on 12/06/2024 01:10 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GOOD SAMARITAN HOME CARE LLC		FACILITY NUMBER:	197610463
ADMINISTRATOR/ DIRECTOR:	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:	12/06/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Emerito Paino- Caregiver/DSP		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

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On 11/22/2024 at 10:00am. Licensing Program Analyst (LPA) Perchui Milena Khurshudyan arrived at this facility to conduct a Required Annual Inspection. LPA was greeted by the Caregiver/DSP Emerito Paino who granted access to the facility. LPA Khurshudyan reviewed the required postings on a wall next to the kitchen area. The inspection tool was used to complete the visit. The Administrator Leila Villon arrived at approximately 11:00am.

At 10:45am. LPA along with Emerito began a physical plant tour of the facility and the following was observed by the LPA: This 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 (4) clients of which two (2) may be non-ambulatory. Facility is operating level 3 clients.

Kitchen: LPA observed a seven-day supply of non-perishable food and a two-day supply of perishable foods; properly stored and labeled. Facility stores the knives, sharps, first aid kit, emergency supply of food and water, client's medications and facility records in a separate locked cabinets in the kitchen. LPA observed two (2) fire extinguishers one (1) is located by the kitchen and the second is by the entrance door, both fully charged with a serviced date of 09/10/2024. A weekly menu was also available.

Common Areas: These include the living areas and the dining areas. LPA observed dining, living areas clean and clear of clutter with furniture in good repair. Dining and living room furniture sits the capacity of the facility. Walls, floors, windows, screens, ceiling fans, and blinds were clean and in good repair. At 11:45pm. LPA measured the room temperature to be 70 degrees Fahrenheit. There is a linen closet by bedroom #1 contained an adequate supply of fresh linens ready to use.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOOD SAMARITAN HOME CARE LLC	FACILITY NUMBER: 197610463
	VISIT DATE: 12/06/2024

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LPA observed a gated fireplace in the living room, and got informed that the fireplace is nonoperational. There was a television and various activities, games, board games stored inside the cabinet located in the living room.

Bedrooms: There are four (4) client bedrooms: three (3) for single use and one (1) shared room. LPA observed bedrooms to be properly furnished with a beds, linens, night stand, a chair, drawers, closet, and adequate lighting. All bedrooms appeared organized and clean.

Bathroom: There are two (2) bathrooms in the facility. The bathrooms contained hand soap, paper towels, toilet paper and trash bins with lids. Hot water temperature was taken in both bathrooms at approximately 12:30pm. and measured 117.9 degrees Fahrenheit. LPA also observed required signs on the bathroom walls, grab bars near the toilet and shower, and a non-skid mat in the shower.

Smoke and Carbon Monoxide Detectors: The smoke and carbon monoxide detectors were tested by a staff at 12:52pm and were observed operational.

Laundry Room & Garage: LPA observed the garage is attached to the facility and has access from the laundry room. The laundry room and garage doors were locked. Disinfectants, laundry detergents and hygiene supplies were stored and inaccessible in a separate locked cabinet in the garage. Also in the garage were extra emergency supplies of food and water, PPE supplies, medical equipment. A functioning washer and dryer was observed at laundry room.

Backyard: LPA observed all emergency exit paths were free from obstructions. Two (2) exit gates were unlocked with self-closing latches. The patio area has appropriate outdoor furniture for clients.

Staff/Client File review: At 11:30am-1:00pm. LPA conducted record reviews for four (4) out of four (4) staff files to insure compliance with licensing forms, and three (3) out three (3) client records were reviewed to insure compliance. Files were complete and updated.

CHOW from Regal Home #197607169 to Good Samaritan Home #197610463 was completed and approved by CCL on 12/1/2023, however, Regional Center has not processed the new Admission Agreements for clients under the Good Samaritan Facility due to processing delay.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GOOD SAMARITAN HOME CARE LLC	FACILITY NUMBER: 197610463
	VISIT DATE: 12/06/2024

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Medications: At approximately 12:15pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). LPA observed centrally stored medication, and First Aid kit locked in the kitchen cabinet and inaccessible to clients in care. LPA observed First-aid kit is complete and has new manual. PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care. Facility operates with three (3) shifts and has three (3) staff members for each shift.

An emergency exit plan/sketch is posted on the kitchen wall along with other posting requirements.

LPAs collected LIC500, LIC9020.

No deficiency cited on today’s visit. Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 12/06/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024

LIC809 (FAS) - (06/04)

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