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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850259
Report Date: 08/11/2022
Date Signed: 08/11/2022 03:59:02 PM

Document Has Been Signed on 08/11/2022 03:59 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 HOMEFACILITY NUMBER:
565850259
ADMINISTRATOR:NASSANGA, FATUMAFACILITY TYPE:
735
ADDRESS:6279 DANA AVETELEPHONE:
(818) 324-9589
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 0DATE:
08/11/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
01:50 PM
MET WITH:Fatuma NassangaTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Martha Arroyo conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Fatuma Nassanga. This will be a new facility. The facility will be a Regional Center vendorized home dedicated for intellectual disability clients.

The facility is a one story home. At 2:00 p.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for two (2) non-ambulatory clients and two (2) ambulatory clients. The facility has four (4) private client bedrooms, Rooms #1, #2, #3, and #5. Two (2) client rooms have direct exits to the outside. All client rooms are set up with beds, night stands, lamps, chests of drawers, chairs, and closet space. The beds are furnished with box springs, comfortable mattress, and clean linen. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair if needed. In addition, no bedroom was used as a passageway to another room, bath, or toilet. Room #4 and #6 are designated staff rooms. All rooms were free of odors. All window screens were clean and maintained in good repair.

There are two (2) bathrooms in the hallway designated for both client and staff use. And Client room #3 has a private bathroom. The client bathroom(s) has a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105 degrees Fahrenheit and 120 degrees Fahrenheit. Client and staff records are stored in a locked cabinet which is currently located adjacent to the living room. Medications are centrally stored in a locked cabinet adjacent to the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a cabinet adjacent to the living room. Kitchen knives are stored in a locked cabinet adjacent to the living room. There are no pesticides or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. ...Report Continued on LIC 809C...
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2022
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 2
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 HOME
FACILITY NUMBER: 565850259
VISIT DATE: 08/11/2022
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...Report Continued from LIC 809...

Kitchen, laundry, and house cleaning supplies will be stored in a locked cabinet located inside the staff room. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There is a television, games, and other activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. There is a fireplace in the living room. It is screened and there are no tools. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility’s main temperature was 75 degrees Fahrenheit at the time of visit. The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is one (1) fire extinguisher throughout the house and it was last serviced on May 2022. The LPA observed the emergency telephone numbers and other required posting in the hallway by the entrance. The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where clients can sit. The back and sides of the house are separated from the front yard by gates at the east and west side passageways. There are no bodies of water on the premises at the present time. The garage is accessible from the house; the doors were unlocked. No toxins or cleaning supplies will be stored in the garage.

Component III was completed in conjunction with the visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure.

Exit interview. Report was reviewed, and a copy was provided to Administrator Fatuma Nassanga.

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

DATE: 08/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2022
LIC809 (FAS) - (06/04)
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