198602362-8-2-2024-31-AS-AAEA-D7RUQ2-20240802154625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198602362
Report Date: 08/02/2024
Date Signed: 08/02/2024 03:46:42 PM

Document Has Been Signed on 08/02/2024 03:46 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:	HARRIET HOUSE		FACILITY NUMBER:	198602362
ADMINISTRATOR/ DIRECTOR:	EASTON, ALYCE		FACILITY TYPE:	735
ADDRESS:	24 W HARRIET		TELEPHONE:	(626) 794-4103
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY: 12		CENSUS: 8	DATE:	08/02/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:50 AM
MET WITH:	Administrator, Magdalena Estrada		TIME VISIT/ INSPECTION COMPLETED:	04:00 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 Analyst (LPA) Antonia Alvizar-Ettima conducted an annual required visit and inspection of the facility. LPA met with staff Professional Direct Support (DSP), Graciella Rincon and Adm. at 9:50a.m. and was advised for the purposed of the visit. At 10:35a.m., with the assistance of Adm., LPA took a tour of the physical plant. Required postings were observed in the entry area. The facility has two houses that has a total of six (6) bedrooms and six (6) bathrooms. The smoke alarms are operational and their carbon monoxide detectors that functions properly. Fire extinguishers were fully charged and inspected on 08/23/2023 for both houses. During the visit the facility is at 70 degrees Fahrenheit. The facility is fire cleared for twelve (12) ambulatory. The facility offers level 4 care to residents. All exit doors of the facility had installed auditory devices/alarms for protection of the health and safety of current facility clients. LPA Alvizar-Ettima walked into the facility and observed three (03) clients in the common areas. Two (02) clients were in their bedrooms. One (1) of the three (3) staff present at the facility, was taking out the trash. The last fire drill was conducted on 07/07/2024. Care and supervision to meet the client’s needs was observed. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. 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 were stored in a locked cabinet in the kitchen. Properly labeled medications were locked in the kitchen cabinets. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away. Continue to LIC 809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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: HARRIET HOUSE	FACILITY NUMBER: 198602362
	VISIT DATE: 08/02/2024

NARRATIVE

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Bedrooms: There were total of six (6) bedrooms designated for residents' use, each house has three (3) bathrooms in the property. For house #1, bedroom #2 is shared and is in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bedroom #1 and #3 are properly furnished and occupied by private residents. For house #2, bedroom #2 is shared and is in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Bedroom #1 and #3 are properly furnished and occupied by private residents.

Bathrooms: There are three (3) bathrooms designated for residents' use in each house. Both bathrooms were properly supplied and contained working fixtures; and appropriate non-slip mats and grab bars were present. Bathroom #1 hot water temperature was measured at 109.4 degrees Fahrenheit and bathroom #2 measured 106.3 degrees Fahrenheit. Bathroom #1 is located in beside bedroom #1. Bathroom #2 is located across bedroom #2. Bathroom #3 is located beside bedroom #3. Cleaning supplies are being stored in a locked cabinet in the cabinet the dining room. There was enough clean linen available in the cabinets in the hallway.

Common Areas: These included the living room and dining area for residents. The common areas were properly
furnished. Furniture in common area was observed to be in good repair. There is no fire place in the facility. No obstructions and or tripping hazards throughout the facility. Residents dining table fits enough for six (6) for both houses. Office is located in the kitchen area beside the patio exit. The laundry area is located by the across bedroom #1 for both houses.

Laundry service: There is enough linen available to change weekly or more if need.
Medications: The medication storage areas were observed in both buildings, locked and inaccessible to the 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. First-aid has all proper items and is current.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. There is no garage. There are no issues with Fire Clearance.

Continue to LIC 809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

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: HARRIET HOUSE	FACILITY NUMBER: 198602362
	VISIT DATE: 08/02/2024

NARRATIVE

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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.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies were not observed/cited. Exit interview conducted and copy of report provided to Administrator.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar-Ettima
LICENSING EVALUATOR SIGNATURE:	DATE: 08/02/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/02/2024

LIC809 (FAS) - (06/04)

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