565850129-2-10-2023-29-AS-MARO-CNX32F-20230210165151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850129
Report Date: 02/10/2023
Date Signed: 02/10/2023 04:51:57 PM

Document Has Been Signed on 02/10/2023 04:51 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 HOME		FACILITY NUMBER:	565850129
ADMINISTRATOR:	NASSANGA, FATUMA		FACILITY TYPE:	735
ADDRESS:	5642 EUNICE AVENUE		TELEPHONE:	(818) 324-9589
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 4		CENSUS: 4	DATE:	02/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Fatuma Nassanga		TIME COMPLETED:	05:00 PM

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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual with focus on Infection Control. The last Annual visit conducted at this facility was on 03/25/2022. Upon arrival, the LPA was scanned and greeted at the door by staff. The Administrator arrived shortly after and the reason for the visit was explained. Entrance Interview.

The LPA along with the Administrator began the physical plant tour of the common areas, kitchen area, client bedrooms, bathrooms, staff room, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA observed two client bathrooms for hot water temperature; the first bathroom measured at 109.6 degrees Fahrenheit at 3:20pm; and the second bathroom measured 107.6 degrees Fahrenheit at 3:26pm. LPA observed an adequate amount of perishable and non-perishable food. LPA observed a shed in the backyard with cleaning supplies and toxins locked and inaccessible. LPA observed fire extinguisher was fully charged on 07/31/2022. At 3:34pm, the smoke detectors and carbon monoxide detectors were tested and operable. LPA observed medications, facility files, sharps and knives in the hallway closet locked and inaccessible to clients. The facility was maintained at 74 degrees Fahrenheit at the time of visit. LPA observed outdoor grounds, there are two gates with self-latching mechanism and clear passageways with no obstructions for emergency use. No bodies of water observed at the time of visit.

Report Continued on LIC 809C ...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: NEW LIFE GROUP HOME	FACILITY NUMBER: 565850129
	VISIT DATE: 02/10/2023

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Report Continued from LIC 809 ...

During today's visit, LPA spoke with the Administrator regarding the facility's infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVlD-19. All staff are fully vaccinated and boosted. The LPA observed staff wearing face coverings at the time of visit. No identified staffing concerns.

Exit interview conducted. No citations issued. Report was reviewed and issued to Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC809 (FAS) - (06/04)

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