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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610541
Report Date: 08/22/2024
Date Signed: 08/22/2024 11:52:48 AM

Document Has Been Signed on 08/22/2024 11:52 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:GODSON HOMEFACILITY NUMBER:
197610541
ADMINISTRATOR/
DIRECTOR:		AMIZE, GIBSON EJIKEFACILITY TYPE:
735
ADDRESS:13637 DRONFIELD AVENUETELEPHONE:
(818) 833-7419
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 4CENSUS: 4DATE:
08/22/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:40 AM
MET WITH:Gibson Amize - AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced Pre licensing visit to this facility on this date. LPA met with Administrator Gibson Amize and explained the purpose of the visit. This is a change of ownership from single proprietorship to a corporation. The applicant is "Godson Home, Inc." Fire clearance dated 12/20/23 was received for four (4) non-ambulatory residents only. This is a North Los Angeles Regional Center (NLARC) vendored facility Level II.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant at 9:15 AM inside and outside and observed the following:

Facility has four (4) client bedrooms; all private rooms. One (1) additional bedroom for staff use; facility has
two (2) bathrooms. There is no body of water in the facility.

Bedrooms were toured and observed to be clean and appropriately furnished. There are sufficient supplies of linen and towels in the linen cabinet.
Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit. There is a working telephone and internet at the facility.
Bathrooms were observed to be clean and with necessary supplies. Hot water temperature measured at a range of 111.3°F to 117.6°F.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/22/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: GODSON HOME
FACILITY NUMBER: 197610541
VISIT DATE: 08/22/2024
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(continued from LIC 809)

Kitchen area was observed to be clean and sanitary. All disinfectants, cleaning solutions and toxins are locked in the cabinet in the garage. Knives and sharps were observed to be locked in the medicine cabinet located near the living room.
Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 75°F and observed to be within the required range.
Fire extinguisher was observed in the dining area wall. Extinguisher was observed to be full and last bought on 08/22/24. Smoke alarms are hardwired and interconnected. There is a carbon monoxide installed in the facility. Alarms were tested and observed to be operational..
Garage is attached to the house. Garage is currently being used as laundry area, frozen foods and other supplies storage. The garage was observed to be locked and inaccessible to residents.
Medications were observed to be locked, inaccessible and stored in a cabinet near the living room. There is a complete first aid kit located in the medication cabinet. Client records were also reviewed. Client records appeared to be complete and updated. Staff records were also reviewed. Staff present has criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate observed to be current.

The backyard of the facility was also inspected to ensure compliance. The backyard activity area is free of obstruction. Outdoor furniture is also observed in the patio and a locked tool shed. There is no body of water in the facility. The exterior passageways and exits were clean and clear of any obstructions. No other health and safety hazard present. Required posters are observed to be posted in the facility (complaint hot line poster).

Component III is waived as the Administrator and staff are the same staff running the facility with the approval of LPM Troy Agard.

The facility appears to be compliant with regulations. A copy of this report will be submitted to the application specialist for final review. An exit interview was conducted and a copy of this report Issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2024
LIC809 (FAS) - (06/04)
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