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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610743
Report Date: 01/21/2025
Date Signed: 01/21/2025 04:54:13 PM

Document Has Been Signed on 01/21/2025 04:54 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:MAYALL HOMEFACILITY NUMBER:
197610743
ADMINISTRATOR/
DIRECTOR:		ANDRES, CHARMILEYFACILITY TYPE:
735
ADDRESS:19638 MAYALL ST.TELEPHONE:
(714) 519-8997
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 4DATE:
01/21/2025
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:30 PM
MET WITH:Charmiley Andres/AdministratorTIME 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 Analysts (LPA) Nadia Shahbazian and Michael Cava conducted a pre-licensing visit and inspection of the facility. LPAs met with Administrators Charmiley Andres, Greg Andres and Xochitl Aragon/Quality Assurance Supervisor with North Los Angeles County Regional Center. An Application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on December 26, 2024 for four (4) bedridden clients. A fire clearance is still pending, an appointment with fire department is scheduled for January 22, 2025. At approximately 12:30 pm, with the assistance of staff, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detector are hard wired and inter-connected. The alarms were tested and are functional. The facility has three new fire extinguishers that were purchased on December 17, 2024. One fire extinguisher is located in dining room/kitchen area, and the other at the hallway, near bedroom and the third one in the garage. The laundry area is located adjacent to the entry area.

Kitchen: The kitchen is equipped with a refrigerator, microwave, oven and dishwasher. The appliances and fixtures were functional. There is sufficient amount of perishable food in the refrigerator and non-perishable foods are properly stored in locked shelves in the garage. Knives were stored in a locked drawer in the kitchen. Medications will be locked in the kitchen; the first aid kit and the manual is dated 2021 will also be kept in the kitchen.

(continued in next page)


SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2025
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 3
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: MAYALL HOME
FACILITY NUMBER: 197610743
VISIT DATE: 01/21/2025
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
Bedrooms: There were four (4) bedrooms designated for Clients' use. All four (4) bedrooms are private with their own closets. Bedrooms were properly furnished with beds, night stands, chairs, dressers. All bedrooms have sufficient beddings and linens.

Bathrooms: There are two (2) bathrooms designated for clients' and Staff use. Bathroom one (1) is near bedroom one (1) and will be mainly used for toilet training and for staff use. Bathroom two (2) is located between bedrooms two (2) and three (3) and will be used as the main client bathroom. Both bathrooms were properly supplied and had functional fixtures, grab bars, and non-skid mats. Hot water temperature was measured from the bathroom one (1) sink at 114.6 degrees Fahrenheit and the bathroom two (2) was measured at 111.4 degrees. No cleaning supplies or hazardous items were present in each bathroom during the inspection.

Common Areas: The dining room is located near the kitchen and there is a living room. There is an additional living/activity room which includes a television, furniture, a keyboard and games. There is a non-functional fireplace with a glass screen. No fireplace tools or fixtures present. The dining area has a large dining room table to accommodate six (6). The living rooms have ample sitting. There were four exit doors leading to the backyard.

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The backyard of the facility has a covered patio and backyard furniture to accommodate the four (4) residents. The facility backyard has sufficient yard and a basketball space. There is no swimming pool but there was a locked shed near the basketball court.

(continued in next page)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: MAYALL HOME
FACILITY NUMBER: 197610743
VISIT DATE: 01/21/2025
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
The Garage: is attached to the house from the kitchen area. LPAs observed the chemicals/toxins are locked and secured in one of the cabinets. There is also an extra freezer and small refrigerator in the garage. A cabinet contains non-perishable food items and is locked. The staff files will also be located in the garage.

Resident Files: clients records will be kept in the dining room. Facility will be maintaining resident P&I which will be maintained in a locked cabinet in the kitchen.

Component III will be waived at this time as both administrators have attended their Component III on 08/07/24. LPA Leslie Ngo conducted that presentation.

Pursuant to title 22, Division 6 of the California Code of Regulation, the physical plant is observed compliant during the day's inspection. A copy of this report issued and CAB will be notified.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3