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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600312
Report Date: 05/08/2024
Date Signed: 05/08/2024 06:38:24 PM

Document Has Been Signed on 05/08/2024 06:38 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTERFACILITY NUMBER:
198600312
ADMINISTRATOR/
DIRECTOR:		CHAMU-NESTOR, FRANCISCAFACILITY TYPE:
735
ADDRESS:753 SOUTH MARIPOSA STREETTELEPHONE:
(818) 843-2695
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 5CENSUS: 5DATE:
05/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:52 PM
MET WITH:Elizabeth Romero - AdministratorTIME VISIT/
INSPECTION COMPLETED:
06:38 PM
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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA initially met with alternate Administrator Elizabeth Romero . Purpose of the visit is stated. This is a Lanterman Regional Center vendored facility Level IV-I Specialized.

LPA conducted physical plant tour inside and out at 3:11 PM. During the tour, LPA observed that the facility has eight (8) bedrooms and three (3) bathrooms. Three (3) bedrooms and one (1) bathroom is designated for staff use. There is no body of water in the facility. The facility is fire cleared for five (5) non-ambulatory residents.

The front main door is the only entrance being utilized at the facility. There is a sign on the front door that every one entering the facility must be screened. Screening area is located immediately before entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and 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

Bedrooms were toured and observed to be clean and appropriately furnished.

Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 116.8°F to 118.6°F. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/08/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KOCH-VAGTHOL'S METABOLIC RESIDENTIAL CENTER
FACILITY NUMBER: 198600312
VISIT DATE: 05/08/2024
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Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean 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 is observed to be clean and sanitary. All disinfectants, cleaning solutions were observed to be locked in the cabinet below the sink
Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.
Fire extinguisher was observed to be located by the kitchen. Extinguisher was observed to be operable and last inspected on 10/20/23. Fire alarms are hardwired and interconnected and observed to be operational. There were carbon monoxide detectors installed in the facility. The facility is equipped with sprinkler system.
Medication were observed to be locked, inaccessible and stored in a kitchen cabinet. There was a complete first aid kit located in the medication cabinet. Knives and sharps are locked and secured in the cabinet below the kitchen sink.
Garage there is no garage at the facility, only car ports located in the backyard. The backyard has a separate two (2) room structure which is currently being used as an office for the administrators and nurses. The other room is being used as frozen and emergency food, PPE and other supply storage. Laundry room is located in a room at the end of the bedroom hallway. Laundry detergent and other toxins are kept locked in a cabinet in the laundry room.
Client records. All of five (5) client records were reviewed. Clients record appeared to be complete and current. Staff records were also reviewed. Four (4) staff records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 04/27/24. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no health and safety hazard observed during the day of inspection.

Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/08/2024
LIC809 (FAS) - (06/04)
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