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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610576
Report Date: 05/21/2024
Date Signed: 05/21/2024 12:32:19 PM

Document Has Been Signed on 05/21/2024 12:32 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:LOUISE HOUSE 3FACILITY NUMBER:
197610576
ADMINISTRATOR/
DIRECTOR:		TILLMAN, WILDA W.FACILITY TYPE:
735
ADDRESS:4824 STARGAZER PLACETELEPHONE:
(661) 526-6876
CITY:PALMDALESTATE: CAZIP CODE:
93552
CAPACITY: 4CENSUS: 0DATE:
05/21/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Wilda Tillman TIME VISIT/
INSPECTION COMPLETED:
12:38 PM
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At 9:30 am Licensing Program Analyst (LPA) Tihesha Smith conducted an announced pre-licensing visit with administrator. Identification of the Applicant/administrator was verified by photo ID.

The facility is a two-story building and has a capacity of four (4). Application received for 4 Ambulatory clients.

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.

Authorization from the Woodland Hills Regional Office on 05/15/2024 and 05/21/2024 allowed the following to be done upon approval of licensing:

Transfer of additional facility furnishings/appliances from previous facility location:

Transfer of Medication cabinet, Personnel and Client files

Transfer of all foods, linen, hygiene items, toxins, supplies, and equipment

Transfer of client furnishings and client personal items

Today's site visit consisted of LPA Smith touring the physical plant inside and outside. and observed the following:

The common areas (kitchen, living room, family room and dining areas) were clean.

(Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/21/2024
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: LOUISE HOUSE 3
FACILITY NUMBER: 197610576
VISIT DATE: 05/21/2024
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(Cont from 809)
Laundry detergents to be stored and locked in laundry room.

There is one (1) fire extinguisher: is located in kitchen near patio door attached to the wall and observed to be fully charged.

Updated facility sketch viewed/to be sent to LPA by:05/22/24.

There are three (3) bathrooms in the facility with two (2) for clients use. The hot water was tested for the bathrooms and measured 115. 9 and 123.3 °F.

There are five (5) bedrooms, with four (4) for clients and one (1) room as a staff office/room.

Extra linen to be stored upstairs in hall cabinets

There is a covered patio for client to conduct outdoor activities.

They are two (2) garages: one (1) attached to house (two car) will be used for parking and one (1) detached to be use for supply storage.

There is no body of water on the facility.

Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested, and observed to be operational at time of visit.

Component III was conducted with the administrator and administrator confirmed understanding of Title 22.

Licensing to be approved on proof of active landline and facility phone number.

This report will be forwarded to the Centralized Application Bureau (CAB).

Exit interview was conducted and a copy of this report provided.



SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 05/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2024
LIC809 (FAS) - (06/04)
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