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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405801701
Report Date: 10/29/2024
Date Signed: 10/29/2024 02:50:48 PM

Document Has Been Signed on 10/29/2024 02:50 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:C.A.L.L.-CARMELITA HOUSEFACILITY NUMBER:
405801701
ADMINISTRATOR/
DIRECTOR:		JONI CHAPMANFACILITY TYPE:
740
ADDRESS:2660 FERROCARRILTELEPHONE:
(805) 466-8502
CITY:ATASCADEROSTATE: CAZIP CODE:
93422
CAPACITY: 6TOTAL ENROLLED CHILDREN: 0CENSUS: 6DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Joni ChapmanTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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At 9:00 am on 10/29/2024, Licensing Program Analyst (LPA) Rankin arrived at facility for an unannounced annual inspection visit. LPA met with Administrator Joni Chapman. During inspection tour of the facility was conducted and records reviewed.

Personnel Records: The facility employes 9 staff and 1 Administrator. Staff records are kept confidential. LPA reviewed 5 staff files for 1st AID/CPR, Fingerprint clearances, Applications, Health exam with TB results, and Criminal Record statement. All required records were reviewed, one staff will be attending 1st Aid/CPR training before returning to the schedule.

Physical Plant & Environmental Safety: The facility is a 5 bedroom and 2-bathroom home currently occupying 6 residents. The facility has dual smoke and carbon monoxide detectors. The lighting and lamps in resident rooms are sufficient for the use of the facility and for resident’s comfort. The facility kitchen is clean, safe, and sanitary. The showers have non-skid flooring. Toilet, hand washing and bathing facilities are operational. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are locked in laundry room and bathroom cupboards. The facility has sufficient space inside and outside for activities and visiting. The facility has a backyard for client use with plenty of shade. The facility has telephone and internet service for resident use.

Clients Rights – Required postings were posted in the common area of the facility, Personal rights and Persons with disabilities as well as the CCL Complaint poster, Ombudsman poster will be requested for posting. The current license along with disaster plan was posted. Internet is provided to each client and each client is given confidentiality and privacy.

Kelly BurleyTELEPHONE: (805) 562-0413
Melisa RankinTELEPHONE: (805) 635-4718
DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: C.A.L.L.-CARMELITA HOUSE
FACILITY NUMBER: 405801701
VISIT DATE: 10/29/2024
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Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks, and drinks are available when the residents want them. Emergency supply of food and water is available. Cleaning solutions and equipment are stored separately than food supply. Kitchen areas are kept clean and free from litter, rodents, vermin, and insects. Kitchen staff are observed for personal hygiene and food sanitation practices.

Disaster Preparedness: The current emergency disaster forms were posted, due to recent change in administrator, updates are being done and will be reviewed during final annual visit. The fire extinguishers were charged. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency.

LPA will return at a later date to complete annual review. Copy of report given to administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:

DATE: 10/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/29/2024
LIC809 (FAS) - (06/04)
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