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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425801208
Report Date: 01/28/2025
Date Signed: 01/28/2025 12:11:23 PM

Document Has Been Signed on 01/28/2025 12:11 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:LE-NA' RESIDENTIAL HOME #3FACILITY NUMBER:
425801208
ADMINISTRATOR/
DIRECTOR:		ESTELA USHERFACILITY TYPE:
735
ADDRESS:475 WILSON COURTTELEPHONE:
(805) 934-2167
CITY:SANTA MARIASTATE: CAZIP CODE:
93455
CAPACITY: 4CENSUS: 4DATE:
01/28/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:15 AM
MET WITH:Estella UsherTIME VISIT/
INSPECTION COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Rankin arrived at 8:15 am to conduct a 1-year annual visit to the facility above. LPA met with Administrator Estella Usher and explained the purpose of the visit.
A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:

Physical Plant & Environmental Safety: All require postings were posted in the common area of the facility. The facility has 4 individual bedrooms and 2 individual bathrooms currently occupying 4 individuals. The facility is clean, safe, and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors, these alarms were tested and were working at time of visit. The lighting and lamps are sufficient for the use of the facility and for individual comfort. 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 inaccessible to individuals locked in the garage. The facility has sufficient space inside and outside for activities and visiting.

Operational Requirements: The facility has a current plan of operation on file with the department. The Facility is operating in compliance with the granted fire clearance.

Personnel Records & Training: The facility employes 8 full time staff and 2 administrators. Staff records are kept confidential. LPA reviewed 5 staff files. Files reviewed and had current 1st Aid/CPR certifications, all other required documents were reviewed. Administrator Certificate expired 1/18/25, but Community Care Licensing shows renewal paperwork was submitted in November of 2024. Annual training was documented and complete.

Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/28/2025
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: LE-NA' RESIDENTIAL HOME #3
FACILITY NUMBER: 425801208
VISIT DATE: 01/28/2025
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Individuals Records & Incident Reports: The facility keeps separate files on each individual confidential. Four files were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID, TB results, Personal Rights, and Safeguard for personal property and valuables, Emergency contact forms, and Appraisal Needs and Services plans (ANS) are done and completed annually. Facility does submit incident reports to the department when required.

Individuals Rights - All required postings were posted in the common area of the facility, Personal rights and Persons with disabilities as well as the CCL Complaint poster. Internet is provided to each individual and each individual is given confidentiality and privacy.

Food Service: The facility kitchen is clean, safe, and sanitary. 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 individuals want them. Cleaning solutions and equipment are stored separately from food supplies.

Incidental Medical Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications for all individual in care are centrally stored. LPA reviewed a sampling of medications and records. No medication labels were altered. Medication is given as prescribed with physician’s orders which are kept with the individual’s records.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts monthly disaster drills. The fire extinguishers were charged and last inspected 1/7/25. 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.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/28/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/28/2025
LIC809 (FAS) - (06/04)
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