565801338-1-7-2025-29-AS-BBAI-DCPTCS-20250107133714

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801338
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:38:04 PM

Document Has Been Signed on 01/07/2025 01:38 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 HOME		FACILITY NUMBER:	565801338
ADMINISTRATOR/ DIRECTOR:	KATHY SHADEKO-ADEDIGBA		FACILITY TYPE:	735
ADDRESS:	1777 ALEXANDER STREET		TELEPHONE:	(805) 306-1766
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 6	DATE:	01/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Administrator - Isaac Adeleke		TIME VISIT/ INSPECTION COMPLETED:	02:00 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) Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 9:40am. Upon arrival LPA met with staff and explained the reason for the visit. At approx. 09:50am, 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. Administrator Isaac Adeleke arrived shortly after. Facility is a single-story residence and consists of a total of four (4) bedrooms and two (2) bathrooms. During physical plant tour LPA observed the required postings throughout the facility. The kitchen appeared to be clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a locked closet in the hallway. Cleaning supplies, toiletries, first aid kits and PPE were observed stored here as well. . LPA observed it to be inaccessible to clients in care. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Hallway closest near Room #2 was observed to be to store a sufficient supply of linen. LPA observed bathrooms to be clean, properly supplied and had functional fixtures. LPA observed non-skid mats. The hot water was measured in each bathroom between 111 - 115 degrees Fahrenheit. LPA observed the common areas. These included two (2) family rooms and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Medications are stored in a locked cabinet next to the sliding door to the backyard. LPA observed it to be inaccessible to residents in care. There is a dedicated area for the posting of required documents directly by the entry way. There is a fireplace in the living room that is non-operable at this time. It is screened and there are no tools.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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 3

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: 01/07/2025

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

Continued from 809

The common areas were observed to be properly furnished and relatively clean at the of the visit.

LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Common room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed fully charged and last serviced Aug 05, 2024.

The exterior passageways were clean and clear of any obstructions. The entire property is not fenced. The back and sides of the house are separated from the front yard by gates at the north and south side passageways. The gate in the backyard has a self-latching mechanism for persons to exit the backyard. LPA observed appropriate furniture for outdoor use. There is no attached garage. There is a staff room, which was only accessible from the exterior. LPA observed room to be empty at this time. There are no bodies of water on the premises at the present time. There is a detached building in the rear of the property. LPA observed it to be used as a storage area at this time. LPA observed a 30 day supply of PPE, incontinent supplies, extra perishable food stored in the an extra fridge and freezer along with a 30 day emergency food supply.

Records review began at approx. 10:30am , (5) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were observed to be in order at this time. At approx. six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were observed to be in order at this time. Last emergency drill was conducted on 12/30/2024.

Medications review began at approximately 11:30am. The medications are centrally stored in a locked storage cabinet near the sliding door. Medications were observed to be properly documented on the centrally stored medications and destruction record.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: 01/07/2025

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

Continued from 809-C

Infection Control : Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. 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 or relocate residents if the facility has a confirmed case of a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Interviews conducted during the visit.

LPA obtained the following documents - Census, staff schedule and emergency disaster plan.

Exit interview conducted and a copy of the report provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

Page: 3 of 3