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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610568
Report Date: 07/10/2024
Date Signed: 08/15/2024 08:10:13 AM

Document Has Been Signed on 08/15/2024 08:10 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:KAYA HOMEFACILITY NUMBER:
197610568
ADMINISTRATOR/
DIRECTOR:		TAMRAT, HILEWNAFACILITY TYPE:
735
ADDRESS:39332 KENNEDY DR.TELEPHONE:
(323) 841-1188
CITY:PALMDALESTATE: CAZIP CODE:
93551
CAPACITY: 4CENSUS: 0DATE:
07/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Hilewna TamratTIME VISIT/
INSPECTION COMPLETED:
11:30 AM
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On 7/10/2024 Licensing Program Analyst (LPA) Melissa Spaeth conducted an announced pre-Licensing visit to this facility and met with the Licensee. This is a new application and a fire clearance dated 3/21/2024 was received for three (3) ambulatory residents and one non-ambulatory resident. Bedroom 1 is designated as the non-ambulatory room. The facility phone number is 661-526-5550.

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. Component III was conducted with the applicant from 9:15 am until 10:15 am.

Today’s site visit consisted of LPA touring the physical plant inside and outside from 10:15 am until 10:45 am. LPA Spaeth observed the following:

Living Room – the living room contained comfortable seating and a television.

Kitchen/Dining Room - The dining room section contained a dining room table and chairs. The facility contained a seven-day supply of non-perishable food and a two-day supply of perishable foods. A fire extinguisher is also located in the kitchen. Appliances in the kitchen appeared to be functional. The cleaning solutions were locked underneath the kitchen sink.. The knives and first aid kit were locked in a kitchen cabinet. The Licensee stated the clients' medications will be safely locked in the kitchen cabinet.

Backyard - The backyard contained a shaded area for residents to enjoy outside activities. There was comfortable seating located in the shaded area. The side gate leading from the backyard to the front yard was not locked.

Continued - 809C
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Melissa Spaeth
LICENSING EVALUATOR SIGNATURE: DATE: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: KAYA HOME
FACILITY NUMBER: 197610568
VISIT DATE: 07/10/2024
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Water Temperature - The water temperature was tested at 10:15 am and was 107.4 degrees F.

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

Office - The facility office will be locked and it contained a locked cabinet for client files and staff files.

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

Hallway Closet - The hallway closet contained games and other activity supplies. LPA Spaeth observed an additional fire extinguisher in this area.

Hallway Cabinet - The hallway cabinet contained additional clean linens and hygiene supplies.

Laundry Room – the laundry room contained the washer and dryer. The laundry room cabinet contained laundry soap and was locked.

Garage – the garage was locked and contained emergency water/food and PPE supplies.

The smoke and carbon monoxide detectors were tested at 10:45 am and were operable. 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: 07/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024
LIC809 (FAS) - (06/04)
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