565850259-8-19-2024-29-AS-MARO-D8AUUC-20240819155318

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850259
Report Date: 08/19/2024
Date Signed: 08/19/2024 03:53:24 PM

Document Has Been Signed on 08/19/2024 03:53 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/ DIRECTOR:	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:	08/19/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:20 PM
MET WITH:	Fatuma Nassanga		TIME VISIT/ INSPECTION COMPLETED:	04:00 PM

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Licensing Program Analysts (LPA), Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there were four (4) staff and two (2) clients. LPA met with the Administrator Fatuma Nassanga and the reason for the visit was explained. Entrance interview.

Beginning at 12:30 p.m., the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Refrigerator and dry food pantry were checked for proper labels and expiration dates and food labels had expiration dates clearly marked. The kitchen faucet was measured for water temperature, and it measured 118.4 degrees Fahrenheit at 12:47 p.m.

BEDROOMS: There are six (6) total bedrooms in the facility; Four (4) bedrooms are designated as private client rooms and two (2) are utilized as staff bedrooms. All client rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

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 HOME	FACILITY NUMBER: 565850259
	VISIT DATE: 08/19/2024

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Report Continued from LIC 809...

BATHROOMS: There are three (3) bathrooms for client/staff use. Bathrooms were observed to be equipped with nonskid surfaces and grab bars. The water temperature was measured between 106.7 degrees Fahrenheit and 107.2 degrees Fahrenheit between 12:34 p.m. and 12:40 p.m.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. Fire extinguisher was observed to be fully charged on 04/18/2024. Hardwired combination smoke and carbon monoxide detectors were tested at 12:44 p.m. and all were functional at the time of the visit. No fire clearance concerns were observed. There is a laundry room with a washer and dryer. Detergents and cleaning solutions were observed in a locked cabinet. Knives and sharp objects were observed inaccessible in a locked cabinet adjacent to the living room.

OUTDOOR/BACKYARD: The backyard has a covered patio area with patio furniture including a table and chairs for client use. All passageways were observed to be clear of any obstructions. There were no bodies of water noted at the time of the visit. LPA observed a shed used for storage locked and inaccessible at the time of the visit. There are two (2) self-latching gates for emergency use.

RECORD REVIEW: LPA reviewed four (4) Client Records at 12:52 p.m. and five (5) Personnel Records including the current Administrator’s file at 1:50 p.m.

Client files were reviewed 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/IPP. All files were complete.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

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 HOME	FACILITY NUMBER: 565850259
	VISIT DATE: 08/19/2024

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Report Continued from LIC 809C...

Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR/CPI training, and the appropriate yearly training. All records were in order.

The Administrator certificate is valid until 08/20/2024. Renewal has been submitted.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill conducted on 08/07/2024.

MEDICATION REVIEW: Medications review began at approximately 3:10 p.m. Medications are locked in a cabinet adjacent to the living room. All medications including PRNs were labeled, stored, and locked inaccessible to clients in care. Medications appeared to be given as prescribed at the time of the visit.

No concerns reported by staff or clients during the inspection.

No citations issued at this time. Exit interview conducted. Report was reviewed and a copy was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 08/19/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2024

LIC809 (FAS) - (06/04)

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