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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802136
Report Date: 06/11/2024
Date Signed: 06/11/2024 05:24:54 PM

Document Has Been Signed on 06/11/2024 05:24 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:TELECARE CARMEN LANEFACILITY NUMBER:
425802136
ADMINISTRATOR/
DIRECTOR:
HANNA DIAZFACILITY TYPE:
772
ADDRESS:212 WEST CARMEN LANE STE 201TELEPHONE:
(805) 212-7680
CITY:SANTA MARIASTATE: CAZIP CODE:
93458
CAPACITY: 12CENSUS: 10DATE:
06/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:55 AM
MET WITH:Hanna Diaz , AdministratorTIME VISIT/
INSPECTION COMPLETED:
05:45 PM
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Licensing Program Analyst (LPA) Erika Miller arrived at the facility unannounced to conduct a required annual visit at 11:55 a.m. LPA met with Hanna Diaz, Administrator and informed her of the reason for the visit. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is following Title 22 Regulations.

KITCHEN: Knives are stored in a locked drawer in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 120 degrees Fahrenheit.

Common areas: Living and dining room furniture were observed to be in good condition. Smoke detector and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was charged and serviced September 19, 2023.

The facility has outdoor seating for client use with plenty of shade. No bodies of water are noted. Laundry room is locked and used for storage of washer and dryer, detergents and other miscellaneous items.

Restrooms: The three client restrooms were clean and sanitary and in operating condition. The bathrooms were sufficiently stocked with soap and paper towels.

Bedrooms: There are six (six) resident rooms consisting of two (2) single rooms and four (4) shared rooms. One shared room is currently vacant.

Records: LPA reviewed resident and staff records . LPA reviewed five (5) resident files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and current needs and services plan.

Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE: DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/11/2024
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: TELECARE CARMEN LANE
FACILITY NUMBER: 425802136
VISIT DATE: 06/11/2024
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The LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification.

INFECTION CONTROL: 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 a single isolation room if needed.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 06/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/11/2024
LIC809 (FAS) - (06/04)
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