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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850432
Report Date: 08/19/2024
Date Signed: 08/19/2024 11:35:21 AM

Document Has Been Signed on 08/19/2024 11:35 AM - 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:PEORIA NEW LIFE HOMEFACILITY NUMBER:
565850432
ADMINISTRATOR/
DIRECTOR:		NASSANGA, FATUMAFACILITY TYPE:
735
ADDRESS:3127 PEORIA AVETELEPHONE:
(818) 324-9589
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 0DATE:
08/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Fatuma NassangaTIME VISIT/
INSPECTION COMPLETED:
11:45 PM
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Licensing Program Analyst (LPA), Martha Arroyo conducted a pre-licensing visit to the facility noted above. LPA met with Applicant Representative, Fatuma Nassanga. The applicant has obtained fire clearance for a total capacity of four (4) clients.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The facility is one story. The facility has four (4) private client bedrooms and four (4) staff bedrooms. Bedrooms #5 and #6 are approved for non-ambulatory only and bedrooms #1, #2, #3, #4, #7, and #8 are approved for ambulatory only. The hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. LPA observed one (1) fire extinguisher to be fully charged and purchased on 08/18/2024.

Client bedrooms are equipped with clean mattresses, pillows, and bedding. Bedrooms have sufficient lighting. There is a sufficient supply of linens, including blankets, bath towels and wash cloths. The facility has four (4) bathrooms for client/staff use. Bathrooms contained appropriate non-skid surfaces and grab bars. Bathrooms have sufficient paper products. Hot water temperature was measured in all bathrooms, and they measured between 105- and 120-degrees Fahrenheit. LPA observed trash cans with tight fitting lids at the time of the visit.

LPA toured the kitchen area at approximately 9:55 a.m. The hot water temperature was measured in the kitchen sink, and it measured 106.5 degrees Fahrenheit. Appliances and all equipment appear to be clean and in good repair. The kitchen has a sufficient supply of plates, cups, cookware, and utensils. Kitchen knives and sharps will be locked in a cabinet adjacent to the dining room.

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)
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: PEORIA NEW LIFE HOME
FACILITY NUMBER: 565850432
VISIT DATE: 08/19/2024
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Report Continued from LIC 809C...

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. Enough seating for six (6) clients at the same time in the dining room table. A working telephone is present. There are activity supplies in the living room. There are two (2) fireplaces which were observed adequately covered. Night-lights were present in the hallways. Medications will be stored and locked in a cabinet adjacent to the dining room. Facility records and First aid kit will be by the medications. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual.

The garage is accessible from the house; the door will be kept unlocked. Additional cleaning supplies and toxins will be stored in locked cabinets. There is a washer and dryer next to the kitchen. LPA observed a locked cabinet with detergents, disinfectants, and cleaning supplies. There will be no firearms/ammunition stored on the property. The facility has required postings, including Emergency Exit Plan, Licensing Complaint Poster, Resident Personal Rights, and Theft and Loss Policy.

The exterior passageways were clean and clear of any obstructions. There are two (2) self-latching gates for emergency use. There are no bodies of water on the premises at the time of the visit. LPA observed the backyard, which has a covered outdoor area with a table and chairs for client use. There is a shed locked and inaccessible which will be used for storage. Cameras were observed in the outside perimeter only.

Physical plant is consistent with the submitted facility sketch/floor plan. The physical plant of this facility location is in compliance with Title 22 regulations at this time.

Comp III conducted with Applicant Representative.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. The 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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