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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850129
Report Date: 03/25/2022
Date Signed: 03/25/2022 02:07:23 PM

Document Has Been Signed on 03/25/2022 02:07 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:NEW LIFE GROUP HOMEFACILITY NUMBER:
565850129
ADMINISTRATOR:NASSANGA, FATUMAFACILITY TYPE:
735
ADDRESS:5642 EUNICE AVENUETELEPHONE:
(818) 324-9589
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 4DATE:
03/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Fatuma NassangaTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced One Year Infection Control Annual Visit. LPA met with staff and reason for visit was explained. A physical plant tour was conducted with staff at approximately 10am.

INFECTION CONTROL: During today’s visit, the LPA spoke with the staff and later with Administrator Fatuma Nassanga regarding the facility’s infection control practices. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The facility’s cleaning protocol observed sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. PPE, cleaning and disinfecting supplies observed sufficient during todays visit.

No deficiencies cited.

Exit interview conducted. Signatures obtained. A copy of the report was emailed.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/25/2022
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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