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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425850568
Report Date: 11/08/2024
Date Signed: 11/08/2024 01:03:32 PM

Document Has Been Signed on 11/08/2024 01:03 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:A CASA BLUE LAKEFACILITY NUMBER:
425850568
ADMINISTRATOR/
DIRECTOR:		SORIANO, APRILYN A.FACILITY TYPE:
735
ADDRESS:1029 BLUE LAKE DRIVETELEPHONE:
(650) 544-1485
CITY:SANTA MARIASTATE: CAZIP CODE:
93454
CAPACITY: 4CENSUS: 0DATE:
11/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:20 AM
MET WITH:Aprilyn Soriano, Admnistrator TIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA), Erika Miller made an announced pre-licensing visit at the location above. LPA arrived at 11:20 a.m. and met with Aprilyn Soriano, Administrator. LPA explained the purpose of the visit.

A tour of the physical plant was assessed, and the following was noted. LPA observed all required signage posted in the entrance way of the front door including emergency plan and telephone numbers. The facility has 6 bedrooms, 2 bathrooms, living room, dining room, kitchen and garage.

Physical plant was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, doors and screens were checked. Facility will be painted soon, and garage door will be replaced. Telephone and internet services are operable. Emergency supplies, flashlights, batteries, are present. The facility does not keep any firearms or ammunition. All passageways and doors are not blocked or obstructed. The physical plant is consistent with the submitted facility sketch/floor plan. The facility has sufficient space to accommodate both indoor and outdoor activities.


Living and dining room furniture were also checked for functionality. The living room is neat and clean along with the family/dining room. The facility maintains a comfortable temperature.

The backyard of the facility has outdoor furniture, with shaded area for clients. There are no bodies of water present. The back and side yards are completely fenced with 1 self-latching and self-closing gate.

The garage is attached to the home and is kept locked inaccessible to clients. Basic laundry equipment is present.

(Cont. 809-C)
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE: DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/08/2024
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: A CASA BLUE LAKE
FACILITY NUMBER: 425850568
VISIT DATE: 11/08/2024
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The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides or toxics were stored and locked away under sink in kitchen or in a locked cupboard in the garage. All sharp objects are locked in a cupboard in the kitchen. Freezer temperature was 0 degrees and refrigerator temperature was at 40 degrees. Dishes, glasses and utensils are sufficient in supply, are clean and in good condition. The hot water measured at 113.7 F in the bathroom at 1:02 p.m..

The resident rooms are adequately furnished with one chair, nightstand, dresser, and sufficient lighting for each client. The mattresses and bedsprings were also checked and in good condition. Clients have sufficient personal hygiene product which is provided by the licensee.

The bathrooms were checked for cleanliness and proper operation. All handrails/grab bars are securely fastened and present for the toilets, showers/tubs. Bathrooms have non-skid mats or textured bottom. Towels and washcloths are not shared. Paper towels and napkins are available in each bathroom for resident use. There is enough linen available to change weekly or more if needed. The smoke and carbon monoxide detectors were tested and working properly. There are no issues with Fire Clearance. Fire Extinguishers are fully charged and last inspected on 10/28/2024.

Medications have a locked storage area in the office. First Aid has all proper items and is current.

Client records and staff records will be stored in a locked cabinet in office.

Exit interview was conducted and copy of report given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Erika Miller
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2024
LIC809 (FAS) - (06/04)
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