565850259-8-25-2023-29-AS-MARO-CV2UK2-20230825153824

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850259
Report Date: 08/25/2023
Date Signed: 08/25/2023 03:40:46 PM

Document Has Been Signed on 08/25/2023 03:40 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 HOME		FACILITY NUMBER:	565850259
ADMINISTRATOR:	NASSANGA, FATUMA		FACILITY TYPE:	735
ADDRESS:	6279 DANA AVE		TELEPHONE:	(818) 324-9589
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 4		CENSUS: 4	DATE:	08/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Fatuma Nassanga		TIME COMPLETED:	03:30 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Martha Arroyo arrived unannounced to conduct a one year required annual visit today. The last annual conducted at this facility was on 08/11/2022. Upon arrival, the LPA was greeted at the door by staff. The Administrator, Fatuma Nassanga arrived shortly after and the reason for the visit was explained. The facility currently has four (4) clients, all which were in day program at the time of the visit. Entrance interview conducted.

The LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen: The LPA inspected the kitchen and food area at 11:10 a.m. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.

Common areas: Living and dining room furniture were observed to be in good condition. At 11:18 a.m., smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The LPA observed required postings throughout the common space. The fire extinguisher was observed to be charged and last serviced in May 2023. Knives and sharps were observed in a locked cabinet adjacent to the living room. There is a room specifically for the washer and dryer. Clients are responsible for their own laundry needs; however, staff will assist if needed.

Outdoor: Cleaning supplies and disinfectants are stored in a locked shed in the backyard. The backyard has a covered outdoor area equipped with furniture for client use. The LPA observed two (2) side gates that are kept unlocked at all times. Outdoor and indoor passageways were observed clear of obstructions in case of an emergency. No bodies of water noted at the time of visit.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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: 08/25/2023

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

(Report Continued from LIC 809...)

Restrooms: There are three (3) client restrooms which are clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature was measured in all restrooms; the first bathroom measured at 117.3 degrees Fahrenheit at 11:05 a.m.; the second bathroom measured at 112.6 degrees Fahrenheit at 11:08 a.m.; and the third bathroom measured at 109.7 degrees Fahrenheit at 11:12 a.m.

Bedrooms: There are four (4) private client bedrooms, which were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed.

Records: The LPA reviewed client records at 11:20 a.m. and personnel records at 12:12 p.m. The LPA reviewed four (4) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All client files were in order.

Three (3) personnel files and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, CPI training, and the appropriate training. All records were in order.

The facility is vendored by Tri-Counties Regional Center (TCRC). The last disaster drill was conducted on 07/22/2023.

Medications: Medications review began at 1:20 p.m.; medications are centrally stored and locked in a cabinet adjacent to the living room. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medication and destruction record. No errors observed during medication review.

Exit interview conducted. No citations issued. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2