<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800274
Report Date: 10/29/2024
Date Signed: 10/29/2024 03:30:09 PM

Document Has Been Signed on 10/29/2024 03:30 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:IRIS HOUSEFACILITY NUMBER:
565800274
ADMINISTRATOR/
DIRECTOR:		BARON GRAHAMFACILITY TYPE:
735
ADDRESS:1311 W. IRIS STREETTELEPHONE:
(805) 486-9288
CITY:OXNARDSTATE: CAZIP CODE:
93033
CAPACITY: 5CENSUS: 4DATE:
10/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:50 PM
MET WITH:Brigitte Campbell, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:40 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 12:50 p.m., the LPA met with staff and explained the reason for the visit. At 2:20 p.m., the Administrator, Baron Graham arrived at the facility. Assistant Administrator, Brigitte Campbell is authorized to sign today’s report. The facility is vendored by Tri-Counties Regional Center as a level 4-I home.

Starting at 1:18 p.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards.

KITCHEN: The LPA observed the kitchen and dining area. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:19 p.m., hot water temperature measured at 106.1-degree Fahrenheit. Knives are stored in a locked cabinet behind the kitchen.

BEDROOMS: There are three (3) client bedrooms downstairs and a staff bedroom upstairs. The LPA observed client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Client restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid materials. Starting at 1:27 p.m., hot water temperature measured between 105.9 and 107.0 -degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels.

OUTDOOR SPACE: At 1:29 p.m., the LPA observed the back and side patio which has a covered outdoor area for client use. There are no bodies of water on the premises. Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
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
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: IRIS HOUSE
FACILITY NUMBER: 565800274
VISIT DATE: 10/29/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
GARAGE: The garage is attached to the house. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage. The laundry units are located inside the garage.

COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 02/20/2024. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 1:38 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Medications are locked and centrally stored in a locked closet in the staff room/office.

RECORD REVIEW: Between 1:40 p.m. and 2:36 p.m., the LPA conducted a file review for all clients and staff regularly scheduled and observed the following: Staff have current first aid. Client records were reviewed for, but not limited to current Individual Programming Plan (IPP), medical records, P & I funds, admissions agreement, and consent forms. All files were in order. The Administrator’s certificate is active and expires on 12/03/2024.

At 2:40 p.m., the LPA conducted a review of medication and medication documentation with the Assistant Administrator for two (2) clients and observed that medications were properly documented and assisted as prescribed.

Starting at 2:50 p.m., the LPA conducted interviews with two (2) clients.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
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)
Page: 2 of 2