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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610659
Report Date: 08/29/2024
Date Signed: 08/29/2024 11:57:28 AM

Document Has Been Signed on 08/29/2024 11:57 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VAGTHOL'S RESIDENTIAL CARE CENTER #1FACILITY NUMBER:
197610659
ADMINISTRATOR/
DIRECTOR:		ROMERO, ELIZABETHFACILITY TYPE:
735
ADDRESS:601 N VALLEY STTELEPHONE:
(323) 788-9924
CITY:BURBANKSTATE: CAZIP CODE:
91505
CAPACITY: 6CENSUS: 0DATE:
08/29/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Elizabeth Romero, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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At 10:00am Licensing Program Analyst (LPA), Angela Panushkina conducted an announced Pre-Licensing visit to the above facility and met with facility Licensee and the Administrator.

Fire Clearance was approved on 08/06/24 for a maximum capacity of six (6) Nonambulatory clients. The Licensee/ Administrator stated the six (6) clients at 6541 Fountain Ave., Los Angeles, CA 90028, Facility #197603802 will be moving to this location. The six (6) bedrooms at the new location are fully furnished. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The facility is a single-story building. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

Kitchen: At 10:15am LPA toured the kitchen area and observed the counters to be clean and clear of clutter. LPA observed a sufficient amount of 2 days perishable and 7 days non-perishable supply food; appropriately stored. Facility stores knives, sharps in the kitchen drawer, under the built in, double oven. Medications, were also observed in the kitchen cabinet kept locked and inaccessible to clients in care.

Common Areas: The living room and dining room area were observed to be clean and clear of clutter. Both areas were properly furnished and sits the capacity of the facility. Laundry room is located in the living room closet and maintained locked and inaccessible to clients in care.

Bathrooms: There are two (2) bathrooms. LPA observed all bathrooms were clean and in good repair, properly supplied with toilet paper, soap and paper towels. The hot water temperature measured between 108.5 and 115.0°F.

Bedrooms: There are six (6) bedrooms designated for client use. All bedrooms were properly furnished, with beds, dressers, clean bedding, linens and sufficient lighting. Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/29/2024
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: VAGTHOL'S RESIDENTIAL CARE CENTER #1
FACILITY NUMBER: 197610659
VISIT DATE: 08/29/2024
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Smoke detectors/carbon monoxide. Smoke and carbon monoxide detectors were located throughout the facility. LPA observed the administrator test the smoke detector that is connected to other detectors through out the facility at 10:30am and observed them to be operational. LPA observed three (3) fire extinguishers fully charged and last serviced on 07/18/24


Component III was conducted with the Administrator.

Based on inspection and observation, the physical plant is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and the applicant will be notified by the CAB Analyst when the license has been approved.

Exit interview was conducted and a copy of this report was provided to the Applicant/Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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