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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198600370
Report Date: 04/04/2022
Date Signed: 04/04/2022 12:08:51 PM

Document Has Been Signed on 04/04/2022 12:08 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ADLA INC. #2FACILITY NUMBER:
198600370
ADMINISTRATOR:AIDINOVA, SALBIFACILITY TYPE:
735
ADDRESS:6731 LENNOX AVENUETELEPHONE:
(818) 997-6216
CITY:VAN NUYSSTATE: CAZIP CODE:
91406
CAPACITY: 4CENSUS: 4DATE:
04/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Steven McDaniels - DSP TIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with DSP Steven McDaniels and explained the reason for the visit. LPA spoke with Administrator Angel over the phone who stated it was okay for Steven to sign for the report. There are (4) clients in care and all were not home at this time.
The facility serves clients from North Los Angeles County Regional Center. Potentially dangerous items are kept inaccessible to clients with developmental disabilities and intellectual disabilities. There is staff to meet the needs of clients with developmental disabilities and intellectual disabilities.

At approx 10am, LPA toured the facility with Steven. The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit. LPs observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in a locked tall dark brown cabinet in the dining area next to the kitchen. LPA also observed resident files, and a first aid kit observed in this cabinet as well. Dining furniture in kitchen and dining room area located to the left of the front door entry appeared to be clean and sufficient at this time.



The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed a sufficient supply of linen and personal hygiene supplies in the hallway closet to the right of the hallway bathroom.

LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom between between 105 - 120 degrees Fahrenheit.
Continued on 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/04/2022
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ADLA INC. #2
FACILITY NUMBER: 198600370
VISIT DATE: 04/04/2022
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Continued from 809-C

Common Areas: These included the living room and (2) dining areas. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Dining room furniture appeared to be relatively clean and functional at this time. Medications were observed stored in locked cabinets in the dining area next to the kitchen. Client files were observed locked in cabinets in this area as well. LPA observed (3) first aid kits properly supplied including an updated first aid manual. Fire extinguisher were observed to be fully charged and last serviced in Jan 2022. LPA observed hallway closet by entrance way to store a 30 day supply of PPE, toiletries and other items for clients use.

Outdoor Area: There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There are no bodies of water on the premises. Garage was accessible from the exterior and interior. LPA observed a sufficient amount of space for activities that make use of exercise equipment. Emergency food supply was stored on shelves in the garage. LPA observed emergency food supply to be sufficient at the time of visit. Laundry area was observed to be clean and well maintained. Cleaning supplies and detergent were observed to be inaccessible at this time. LPA did not observe any obstructions to emergency exits at this time.

The LPA spoke with Steven regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate the master bedroom as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted. Report issued and sent via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 04/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

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