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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801338
Report Date: 12/10/2022
Date Signed: 12/10/2022 12:00:47 PM

Document Has Been Signed on 12/10/2022 12:00 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NODOT HOMEFACILITY NUMBER:
565801338
ADMINISTRATOR:KATHY SHADEKO-ADEDIGBAFACILITY TYPE:
735
ADDRESS:1777 ALEXANDER STREETTELEPHONE:
(805) 306-1766
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 5DATE:
12/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:58 AM
MET WITH:Abiodun Adedigba, Kathy Shadeko-Adedigba TIME COMPLETED:
11:15 AM
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 conducted an unannounced required annual visit. At 9:58 a.m., the LPA met with staff and explained the reason for the visit. At 10:44 a.m., the Administrator arrived at the facility. The Administrator authorized staff, Abiodun Adedigba to sign the report. This annual had a specific emphasis on infection control practices and procedures. When the LPA arrived, there was three staff and five clients present.

At 10:20 a.m., the LPA, along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA observed the kitchen/dining area. Knives and cleaning supplies are stored in a locked storage closet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:23 a.m., hot water measured at 105.1-degree Fahrenheit.

COMMON SPACES: All indoor and outdoor passages were free of obstruction. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the fire extinguisher to be fully charged and last serviced on 08/24/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 10:29 a.m., fire alarms and carbon monoxide detectors were tested and functioning properly. Medications are centrally stored and in a locked filing cabinet near the living room.

BEDROOMS: There are four client bedrooms. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Continued on LIC 809-C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/10/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NODOT HOME
FACILITY NUMBER: 565801338
VISIT DATE: 12/10/2022
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
RESTROOMS: Restrooms were observed to be clean and sanitary with hand soap, toilet paper and paper towels. At 10:25 a.m., the hot water temperature tested at 113.7-degree Fahrenheit.

OUTDOOR SPACE: At 10:15 a.m., the LPA observed the back patio which has a covered outdoor area for client use. There are self-latching gates on each side of the yard. The LPA observed locked storage shed, and staff office, where emergency food and water is stored, along with additional refrigerator with supply of non-perishable and perishable food items.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. The LPA observed a 30-day supply of Personal Protection Equipment (PPE). The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report will be provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2