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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850129
Report Date: 05/17/2024
Date Signed: 05/17/2024 01:48:00 PM

Document Has Been Signed on 05/17/2024 01:48 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/
DIRECTOR:		MOSES T BAHINGIREFACILITY TYPE:
735
ADDRESS:5642 EUNICE AVENUETELEPHONE:
(818) 324-9589
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 4DATE:
05/17/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:00 AM
MET WITH:Fatuma NassangaTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 03/26/2024. Upon arrival, there were four (4) staff and one (1) client present. LPA met with staff and and the reason for the visit was explained. Staff contacted the Administrator, Fatuma Nassanga telephonically and LPA informed them of the purpose of today's visit. The Administrator arrived during the inspection. Entrance interview.

During today’s visit, at 9:17 a.m., the LPA along with staff toured the physical plant areas to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations and conducted a medication review. The following was noted:

The LPA observed two (2) client restrooms, which were clean and sanitary and in operating condition with non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The LPA observed four (4) client bedrooms, which were furnished appropriately and had sufficient lighting. The LPA inspected the kitchen area at 9:25 a.m. The facility has a sufficient supply of perishable and non-perishable food. LPA observed fire extinguisher was fully charged on 04/18/2024. No bodies of water noted at the time of the visit. All indoor and outdoor passageways were free from obstructions in case of an emergency.

Continued on LIC 809C...
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/17/2024
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: 05/17/2024
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Continued from LIC 809...

Records: Records review began at 9:39 a.m.; four (4) client records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan. All client files were in order.

Six (6) personnel records including the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Files were complete.



The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 4i home.

The last emergency disaster drill took place on 05/04/2024.

LPA conducted one (1) staff interview during the inspection.

Medications: Medications review began at approximately 11:25 a.m. The medications are centrally stored in a locked closet by the main entrance hallway. All medications including PRNs were labeled, stored, and locked inaccessible to clients. PRNs have physicians order on file. Medications appeared to be given as prescribed.

Exit interview conducted. No citations issued. Report was reviewed and a copy was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 05/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2024
LIC809 (FAS) - (06/04)
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