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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610540
Report Date: 08/19/2024
Date Signed: 08/19/2024 01:55:34 PM

Document Has Been Signed on 08/19/2024 01:55 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:NINA RESIDENTIAL HOMEFACILITY NUMBER:
197610540
ADMINISTRATOR/
DIRECTOR:		ACHIENG, ANTONIAFACILITY TYPE:
735
ADDRESS:18215 SEPTO STTELEPHONE:
(818) 796-9816
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 4CENSUS: 0DATE:
08/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:59 AM
MET WITH:Antonia Achieng, AdministraorTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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On 08/19/24, at 10:00am, Licensing Program Analyst (LPA), Gina Saucedo, conducted an announced visit to the facility for purpose of a pre-licensing evaluation and met with Antonia Achieng, Administraor.

An application was submitted to Community Care Licensing Division-CCLD on 12/2023, Initial license for a Adult Residential Facility (ARF). The requested capacity is for four (4) ambulatory clients.

Facility is a single-story home. Today's site visit consisted of LPA touring the physical plant at 10:50 AM inside and outside and observed the following:

Temperature:
The temperature was kept at 74 degrees.

Bedrooms Staff:
There is no bedroom designated for staff.

Bedrooms and Bathrooms Clients:
There is a total of four (4) bedrooms and two (2) and half bathrooms. One (1) of the bedrooms has a private bathroom. There is another bathroom in the hallway and a half-bathroom where the washer and dryer are located. All the bedrooms have proper bedding, chairs, nightstands, lamps in addition to overhead lighting. There is an office area on your left-hand entrance of the facility next to the kitchen.

LIC 809C-continued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2024
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: NINA RESIDENTIAL HOME
FACILITY NUMBER: 197610540
VISIT DATE: 08/19/2024
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The dining/living room Client & Staff Files:
There is enough seating for staff and clients. The furniture is in good condition. The client/staff files will be kept in a closet at the entrance of the facility where the medication and first aid are locked, secured and inaccessible to the clients.

Linens & Hygiene Supplies:
Adequate supply of linen stored in one (1) of the cabinets in the hallway.

Emergency Phone Numbers, Exit Plan & Menu:


The facility has a working phone number land line in the living room. Fire Extinguisher located in the kitchen on your right-hand side mounted on the wall. It is fully charged.

Food Service:
Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Sharps are stored under the kitchen cabinet locked and secured inaccessible to the clients. Food supply adequate stored in several cabinets and consists of the following: canned goods, bottles of water, cereal, emergency buckets. The refrigerator, stove and microwave are in good condition and working.

Smoke Detectors:
There are smoke detectors/carbon monoxide through-out the house that were tested and work properly. They are hardwired and interconnected with the doors for an emergency.

Water Temperature:
The water temperature was tested for the bathrooms are they are within regulation:113.-116 Fahrenheit.

LIC 809C-continued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
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: NINA RESIDENTIAL HOME
FACILITY NUMBER: 197610540
VISIT DATE: 08/19/2024
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Pool/Jacuzzi:
There is no pool/jacuzzi in the facility.

Fire clearance:
Fire Clearance was approved on 04/2024 signed and dated.

Signal system:


The facility does not have a signal system installed. The facility phone number (818) 678-9325.

Administration:
The facility has submitted a Emergency and Disaster Plan and Infection Plan have been submitted. The signs are going to be against the wall at the entrance of the facility on your right-hand side.

The Component III Orientation Adult Residential Facility (ARF) was shown to the Administrator.

Structure:
Overall Facility is a four (4) bedroom home with two and half (21/2) bathrooms, single-story home. There is a garage that is attached to the house and can be accessed via the office area. The office area is next to the kitchen. The home has a fireplace which has a covering in the living area. There is one (1) washer and dryer located in the hallway which is locked and inaccessible to the clients. The chemicals will be kept above the cabinets where the washer and dryer are located which are also locked, secured and inaccessible to the clients.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.



Exit interview conducted and copy of this report issued to the administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 08/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024
LIC809 (FAS) - (06/04)
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