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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610545
Report Date: 06/05/2024
Date Signed: 06/05/2024 03:31:26 PM

Document Has Been Signed on 06/05/2024 03:31 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:POTTER'S HOUSEFACILITY NUMBER:
197610545
ADMINISTRATOR/
DIRECTOR:		WHALEY, NICOLEFACILITY TYPE:
735
ADDRESS:4326 SUNGATE DRIVETELEPHONE:
(661) 206-7766
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 0DATE:
06/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Nicole WhaleyTIME VISIT/
INSPECTION COMPLETED:
11:45 AM
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On 6/05/2024, Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced pre-Licensing visit to this facility and met with the Licensee/Administrator. This is a new application and a fire clearance dated 01/16/2024 was received for four (4) ambulatory residents.

The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6. The component III orientation was conducted with the applicant from 9:40 am until 10:15 am.

Today’s site visit consisted of LPA touring the physical plant inside and outside from 10:15 am until 10:55 am. LPA Spaeth observed the following:

Dining Room – LPA Spaeth observed a dining room table and chairs in the room. The fire extinguisher is located near the kitchen and was operable.

Kitchen/Family Room - The facility contained a seven day supply of non-perishable food and a two day supply of perishable foods. Appliances in the kitchen appeared to be functional. The first aid kit, cleaning solutions, and knives were safely locked underneath the kitchen sink. The client medication containers were also safely locked in a kitchen cabinet. The family room contained comfortable seating, games, and a television

Backyard - The backyard contained a shaded area and comfortable seating so that residents may enjoy outside activities. The side gate leading from the backyard to the front yard was not locked.

Continued - 809-C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/05/2024
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: POTTER'S HOUSE
FACILITY NUMBER: 197610545
VISIT DATE: 06/05/2024
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Laundry area - The washer and dryer are located in a laundry area. The laundry detergent was safely locked in a cabinet. LPA observed a shelf within the locked cabinet which will be the location for the clients' files.

Garage - The garage contained emergency water and emergency food.

Bedrooms - There are four bedrooms which contained a bed, linens, night stand, lamp, chest of drawers, a chair, client hygiene items, a television, and a closet.

Bathrooms- There are three bathrooms which contained hand soap, paper towels, slip resistant mats and a trash can.

Office - The staff files and the clients' P & I money will be safely locked in a four-drawer cabinet within the room.

Smoke/Carbon Monoxide Detectors - The smoke/carbon monoxide detectors were tested at 10:55 am and were operable.

Water Temperature- The water temperature was tested at 11:15 am and was 106.2 degrees F.

The facility was clean and appears to be in good repair.

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.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE:

DATE: 06/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/05/2024
LIC809 (FAS) - (06/04)
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