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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800642
Report Date: 09/16/2022
Date Signed: 09/16/2022 11:53:46 AM

Document Has Been Signed on 09/16/2022 11:53 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:NBC GUEST HOMEFACILITY NUMBER:
197800642
ADMINISTRATOR:NANCY M STA. ROMANAFACILITY TYPE:
735
ADDRESS:2368 ADDISON WAYTELEPHONE:
(323) 254-4395
CITY:LOS ANGELESSTATE: CAZIP CODE:
90041
CAPACITY: 6CENSUS: 5DATE:
09/16/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Violeta Navarro - StaffTIME COMPLETED:
12:00 PM
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A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with staff Violeta Navarette who called the Administrator and purpose of the visit stated. LPA observed that all five (5) residents were at the facility during visit. Administrator designated Ms. Navarro to sign the report.

A tour of the physical plant was conducted at 9:15 AM and the following was noted:

The front main door is the only entrance being utilized at the facility. There is a sign on the front door that everyone entering at the facility must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask.

The facility had submitted approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the front yard. The facility has sufficient stock of PPE in the storage

The facility is a single storey house and has five (5) bedrooms and two (2) bathrooms. Two (2) bedrooms are designated for staff use. There is no body water in the facility.

(continued to LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/16/2022
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: NBC GUEST HOME
FACILITY NUMBER: 197800642
VISIT DATE: 09/16/2022
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continued from LIC 809)

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.

Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature was measured at a range of 117.7°F to 118.7°F and within the required range.

Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.

Kitchen area was observed to be clean and sanitary and free of pests. Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable. Laundry area is located at the side of the building. Knives and sharps are observed to be locked in the kitchen drawer. All toxins, cleaning agents and laundry soap are locked in the cabinet under the kitchen sink.

Fire extinguisher - There are three (3) fire extinguishers located in the dining area, recreation area and kitchen. Extinguishers were observed to be operable and current. Smoke and carbon monoxide alarms were hardwired and inter connected, tested and observed to be operational. Temperature of facility wall thermostat was set at 75°F and observed to be within the required range.

Garage is detached and has no access from inside the house. The garage is also being used as storage for old equipment and supplies.

Medication was observed to be inaccessible and stored in a secured medication cabinet in the kitchen. There is a complete First Aid kit in the kitchen.



There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2022
LIC809 (FAS) - (06/04)
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