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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850081
Report Date: 12/11/2024
Date Signed: 12/11/2024 02:08:01 PM

Document Has Been Signed on 12/11/2024 02:08 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:STADIUM PLACE HOMEFACILITY NUMBER:
425850081
ADMINISTRATOR/
DIRECTOR:		CINDY BAKERFACILITY TYPE:
734
ADDRESS:961 STADIUM PLACETELEPHONE:
(805) 691-9036
CITY:SOLVANGSTATE: CAZIP CODE:
93463
CAPACITY: 5CENSUS: 5DATE:
12/11/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Cindy BakerTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Melisa Rankin arrived unannounced to conduct a one year required annual inspection. LPA met with Administrator Cindy Baker and explained the reason for the visit.

At time of visit there were four clients on site, one was away with family. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The facility has a sufficient supply of non-perishable and perishable food items. Cleaning supplies and disinfectants are stored and locked inaccessible to clients. Knives are stored in a locked drawer.

Common areas: Living and dining room furniture were observed to be in good condition. LPA observed required postings throughout the common space. The backyard has a covered area for shade and is equipped with furniture for client use. No bodies of water noted. The washer and dryer are in the garage and locked.

Restrooms: The two client restrooms were clean and sanitary and in operating condition. There is an additional restroom for staff. Hot water temperature is measured and charted daily by the facility. Restrooms had equipment in support of the clients and their needs.

Bedrooms: There are five (5) client rooms, which were furnished with appropriate linens and required furniture.

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SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/11/2024
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: STADIUM PLACE HOME
FACILITY NUMBER: 425850081
VISIT DATE: 12/11/2024
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Records: LPA reviewed client and staff records. Five (5) client files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, and needs and services plans. All files were complete. LPA reviewed five (5) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid certification. All files were complete.

Medications: A sampling of medications was reviewed, counted, and checked against the Centrally Stored Medication Record. Facilities medications are centrally stored and locked in a medication cart. Narcotics are counted during each shift change.

The facility is supported by Tri-Counties Regional Center (TCRC) as an Adult Residential Facility for Persons with Special Health Care Needs. The disaster drills are conducted monthly with a variety of scenarios. Facility has emergency food, and water, a back-up generator, and necessary procedures for emergency processes. Facility has 2 fire extinguishers that are charged and scheduled for an inspection, they have hardwired smoke and carbon monoxide detectors that are tested each month during the emergency drills, and a sprinkler system.

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

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 12/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2024
LIC809 (FAS) - (06/04)
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