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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610544
Report Date: 08/06/2024
Date Signed: 08/06/2024 01:16:57 PM

Document Has Been Signed on 08/06/2024 01:16 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:NOBLE RESIDENTIAL HOMEFACILITY NUMBER:
197610544
ADMINISTRATOR/
DIRECTOR:		KAWOOYA, DAVIDFACILITY TYPE:
735
ADDRESS:10837 SUNNYBRAE STTELEPHONE:
(747) 263-5206
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 4CENSUS: 0DATE:
08/06/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:David Kawooya, Administrator TIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Angela Panushkina met with David Kawooya, Administrator/Applicant, for a Pre-licensing inspection at 10:00am.

Entrance interview conducted.

The home will be vendored by North Los Angeles Regional Center. The home will serve four (4) level 3 intellectually disable adults. Clients will be all ambulatory. The facility has 4 bedrooms and 2½ bathrooms designated for a capacity of 4 clients. There is one bedroom designated for staff. Staff will be awake at night.
The physical plant was toured inside and out.

Common Area:
LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The facility maintains a comfortable temperature at 75 degrees F which meet regulations. The air conditioner is operational. The smoke alarm and carbon monoxide detector were operational. Fire extinguishers was last purchased on 11/29/23.

Resident rooms: LPA observed all four (4) rooms are private and have bedding sheets, pillowcase, blankets, which are in good condition. There is at least one chair, night stand and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition. Window covering and window screens are in good repair.

Consumers will have sufficient amounts of supplies for personal hygiene products which is provided by the Licensee. Medications and files will be kept centrally stored and locked in a hallway closet.
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/06/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NOBLE RESIDENTIAL HOME
FACILITY NUMBER: 197610544
VISIT DATE: 08/06/2024
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Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 119.3 degrees F. LPA observed appropriate non-skid mat in each shower. Trash cans had lids to protect consumers from cross contamination. Towels and washcloths will not be shared.

Kitchen Area: LPA inspected kitchen equipment. The refrigerator was clean and in good operation. Dishes in good repair. Knives and cleaning supplies will be kept locked inaccessible. Stove and refrigerator is clean and in good operation. LPA observed sufficient supply of 7 day non-perishable foods.

LPA toured the outside area. LPA observed a covered shaded area for clients. No bodies of water.
Garage: The garage is accessed from outside. It is maintained locked inaccessible to clients.

LPA discussed preplacement, staffing, training, customer service, inspection authority, reporting requirements(mandated reporter), records, citations, criminal record clearance, civil penalties, labor law, activities, expectation is to follow all rules and regulations.

Smoke detectors and carbon monoxide were located throughout the facility. At 11:30am they were tested and observed to be operational.

Licensee was encouraged to sign up for sit alerts and guardian for future use and notifications. The Administrator was informed to notify the LPA regarding the first client/resident being admitted to the facility.



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

Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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