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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197800642
Report Date: 09/20/2024
Date Signed: 09/20/2024 03:30:00 PM

Document Has Been Signed on 09/20/2024 03:30 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:NBC GUEST HOMEFACILITY NUMBER:
197800642
ADMINISTRATOR/
DIRECTOR:
NANCY M STA. ROMANAFACILITY TYPE:
735
ADDRESS:2368 ADDISON WAYTELEPHONE:
(323) 254-4395
CITY:LOS ANGELESSTATE: CAZIP CODE:
90041
CAPACITY: 6CENSUS: 5DATE:
09/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Violeta Navarro, Caregiver / Bernadette Manalo, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Antonia Alvizar-Ettima conducted an Required One (1) year annual visit and inspection. LPA met with Caregiver who called the Administrator and purpose of the visit stated. Later Administrator joined us. LPA observed that one (1) resident were at the facility during visit.

At 11:00a.m., with the assistance of Caregiver, LPA took a tour of the physical plant. Required postings were observed in the breakfast nook, family room and dining area. The facility is a single-story house in a residential community with five (5) bedrooms and two (2) bathrooms. Two (2) bedrooms are designated for staff use.

The facility is fire cleared for six (06) non-ambulatory. The facility offers level four (4) care to clients. The last fire drill was conducted on 07/15/2024. Care and supervision to meet the client’s needs was observed. There is no body water in the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:
Bedrooms were toured and observed to be clean and properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be properly supplied and contained working fixtures; and appropriate non-slip mats and grab bars were present. Hot water temperature was measured at a range of 114.9°F to 117.1°F and within the required range. Client’s personal hygiene supplied is in a box labeled with their name locked in bathroom cabinet.

(continued to LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE: DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/20/2024
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NBC GUEST HOME
FACILITY NUMBER: 197800642
VISIT DATE: 09/20/2024
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Common Areas: These included the living room, family room and dining area for clients. The common areas were properly furnished. Furniture in common area was observed to be in good repair. There are two fireplace that are closed and are not in use. No obstructions and or tripping hazards throughout the facility. Clients dining table fits six (6) and the breakfast table sits (4) clients. There was enough clean linen available in the cabinets in the living room.
Kitchen Area was observed to be clean and sanitary and free of pests. The kitchen appliances and fixtures were functional. Food: LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in the kitchen drawer. All toxins, cleaning agents are locked in the cabinet under the kitchen sink.
Laundry Area is located at the side of the building and has no access from inside the house. Detergent is kept in the laundry area locked and inaccessible to clients.
Fire extinguisher - There are three (3) fire extinguishers located in the dining area, family room and kitchen. Extinguishers were observed to be operable and purchased on 09/20/2024. Smoke and carbon monoxide alarms were hardwired and inter connected, tested and observed to be operational. Temperature of facility wall thermostat was set at 72°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. Medication is inaccessible to clients. Medication and Medication Records (MMR) were review for proper documentation. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. There is a First Aid kit in the kitchen and has all proper items. Surrounding Grounds: Entry and exits were free of obstruction and was checked for cleanliness and condition. There was furniture appropriate for outdoor use. The outdoor area was free of hazards during today’s visit. The facility does not have a swimming pool or body of water.

In addition to the physical plant LPA conducted a file review for all clients and staff regularly scheduled. Staff have current first aid and training documentation showing training completed. Resident records observed to be complete at this time.



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 Administrator.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024
LIC809 (FAS) - (06/04)
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