565850244-6-12-2024-29-AS-MRAN-D66RW5-20240612132235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850244
Report Date: 06/12/2024
Date Signed: 06/12/2024 01:22:40 PM

Document Has Been Signed on 06/12/2024 01:22 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PALS SKILLS CENTER		FACILITY NUMBER:	565850244
ADMINISTRATOR/ DIRECTOR:	POURAN MOUSAZADEH		FACILITY TYPE:	775
ADDRESS:	1310 E MAIN STREET		TELEPHONE:	(562) 489-3859
CITY:	SANTA PAULA	STATE: CA	ZIP CODE:	93060
CAPACITY: 30		CENSUS: 7	DATE:	06/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Pouran Mousazadeh		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Melisa Rankin arrived at the facility unannounced to conduct a required annual visit at 9:15 a.m. The LPAs met with Administrator Pouran Mousazadeh and explained the reason for the visit. Upon arrival, there were 4 consumers observed in the building, with a total census today of seven (7), shortly after arriving all but one consumer left on an outing with staff. The program currently operates from 8:00 a.m. to 2:00 pm. There were seven (7) staff working today.

Common Activity Space: The facility is a single-story structure with a large conference/training room, a lobby, office staff room, an office, one (1) relaxing room, one (1) art room, two (2) computer areas, two (2) bathrooms, and two (2) kitchens. The LPA did not observe any obstructions or hazards. Furniture and equipment was observed to be in good condition. The LPA observed fire extinguishers throughout the facility, which were last serviced in June of 2023, there is an annual service scheduled for 6/13/24.

Activities: Activities are both designed for individual and as a group. Six (6) of the nine (9) enrolled Consumers went to an outing at the start of the visit; and all returned prior to the end annual visit and an interview was conducted with one (1) Consumer.

Food Service: The kitchen areas were clean and in good condition. Consumers bring their lunch and snacks. The facility has emergency food supplies and snacks available for consumers.

Restrooms: Restrooms were clean and sanitary and stocked with soap and paper towels. At 10:32 a.m., water temperature in the kitchen was measured at 120 degrees Fahrenheit. The hot water measured was within the required limit of 105-120 degrees Fahrenheit.

Report will continue on LIC809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: PALS SKILLS CENTER	FACILITY NUMBER: 565850244
	VISIT DATE: 06/12/2024

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Training Records: At 11:40 a.m. training records were reviewed. Emergency drills are held every two months for Consumer and staff repetition and comfort with process. Monthly there is an hour-long training conducted going over various topics such has medication, driver responsibilities, certain health conditions such as seizures, etc. Daily at 7:00 am staff have an hour-long meeting prior to program start to discuss Consumer progress, concerns, go over training needs, and ensure all elements of their Consumers is being communicated and observed. A sampling of First aid and CPR requirements were reviewed and all were found to have current CPR/First Aid cards.

Record Review: At 11:00 a.m. a review of facility files was initiated. The LPA obtained consumer Roster, Staff Roster, and reviewed facility Sketch. The LPA reviewed three (3) of nine (9) Consumer Files. The LPA reviewed three (3) of six (6) staff files. One (1) of three (3) staff files did not have LIC 503 Health screening form. Administrator promptly provided a copy of the LIC 503 as well as documents signed by a physician answering the Health Screening questions.

Medications: Three (3) consumers medication was reviewed for accuracy, tampering, and records keeping. All medication records were available and secured in a locked cabinet in the storage room.

Infection Control: Facility has a sufficient supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol was sufficient. The facility's procedures as it pertains to infection control are adequate.

Interviews: During today's visit, the LPA interviewed two (2) staff and one (1) consumer. No immediate concerns voiced at this time.

Exit interview conducted and copy of the report provided to Administrator.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2024

LIC809 (FAS) - (06/04)

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