<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610623
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:23:25 PM

Document Has Been Signed on 09/04/2024 03:23 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TLC GROUP HOME LLCFACILITY NUMBER:
197610623
ADMINISTRATOR/
DIRECTOR:		GAJETE, THERESE VFACILITY TYPE:
735
ADDRESS:7928 FARRALONE AVENUETELEPHONE:
(818) 636-1133
CITY:WEST HILLSSTATE: CAZIP CODE:
91304
CAPACITY: 4CENSUS: 4DATE:
09/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Maria V Montana-CaregiverTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection with the facility Administrator Therese V Gaiete. This is a Change of Ownership Application from facility #197602380 to #197610623 to operate an Adult Residential Facility Level 2. A Change in Ownership (CHOW) Application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on April 26, 2024. A fire clearance was approved on August 26, 2024 for four (4) ambulatory clients for a total capacity of four. The smoke alarms and carbon monoxide detector are hard wired and inter-connected. The facility has one fire extinguishers that was purchased on November 20, 2023 and is located in living room area.

A tour of the physical plant was initiated at approximately 11:30am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of four (4). Knives and other sharps were observed locked in a hallway drawer.

BEDROOMS: The facility has 5 bedrooms, four (4) bedrooms are designated for clients' private use and one (1) bedroom for staff use. The applicant furnished all clients' bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has three (3) bathrooms, two (2) are designated for clients' use, and one (1) is for staff use only. Bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids. The hot water delivered in the bathrooms measured at 11:45am to be at 111.7 degrees.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/04/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TLC GROUP HOME LLC
FACILITY NUMBER: 197610623
VISIT DATE: 09/04/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
COMMON AREAS: These included two (2) living rooms and a dining room. The living rooms were equipped with furniture, a television, tables and chairs. There is a fireplace with a screen. It is non-operational. No fireplace tools or fixtures present. The dining area has a dining room table to accommodate four (4) clients. There were no visible immediate hazards.

GARAGE/LAUNDRY ROOM: The washer and dryer is located in the garage, which is kept locked. The garage is also used as extra storage for non-perishable and emergency food supplies and water. There is another freezer/refrigerator in the garage for additional food items.

MEDICATIONS: The medications are kept locked in a hallway cabinet. At approximately 12:00pm to 1:00pm LPA observed each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. All medications are properly labeled and checked for expiration dates. First Aid and the new manual is also locked in the cabinet. LPA observed the First-aid has all proper items and is current.

Resident Files: LPA conducted a file review of all client records to insure compliance of licensing forms. Resident files are complete and kept locked in cabinet, in the hallway.

Staff Files: Staff files are also kept in a locked cabinet in the hallway area. LPA conducted staff file review, files were complete with all documents and training certificates.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. The backyard of the facility has a patio and backyard furniture to accommodate the four (4) clients. The facility backyard has sufficient yard space. There is no body of water.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised.

Exit interview conducted and copy of this report signed and delivered to the Administrator

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2