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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850572
Report Date: 12/06/2024
Date Signed: 12/06/2024 12:17:36 PM

Document Has Been Signed on 12/06/2024 12:17 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:MEDO PEACEFUL HOMEFACILITY NUMBER:
565850572
ADMINISTRATOR/
DIRECTOR:		TAYEBWA, ONESMUSFACILITY TYPE:
735
ADDRESS:2274 WALDO STREETTELEPHONE:
(818) 770-9074
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 4CENSUS: 0DATE:
12/06/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Onesmus TayebaTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted a pre-licensing visit to the above noted facility.  The LPA met with applicant Onesmus Tayeba The fire clearance was granted for four (4) ambulatory client. They are vendored with Regional Center for Level III clients.

The facility is one story.  At approx. 10:10am, a physical plant tour was conducted inside and out.  The facility has four (4)  private resident bedrooms.   There are no fire sprinklers in the facility.

All resident rooms are set up with beds, night stands, lamps, chests of drawers, chairs and closet space.  The beds are furnished with comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate.  In addition, no bedroom was used as a passageway to another room, bath or toilet.  There are no staff rooms in the facility. LPA observed rooms to be made inaccessible to residents in care. For NOC , there will be awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair.

There are two (2) bathrooms total. The resident bathroom(s) have 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*F and 120*F.

Resident and staff records are to be stored inaccessible in the hallway closet.   Medications are to be centrally stored inaccessible in a locked cabinet next to bedroom #1. The first aid supplies were complete , including a thermometer and a current version of a first aid manual. First aid was observed stored inaccessible in the locked cabinet as well.

Continued on 809
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/06/2024
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: MEDO PEACEFUL HOME
FACILITY NUMBER: 565850572
VISIT DATE: 12/06/2024
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Continued 809
Kitchen knives and other sharp objects are stored inaccessible in a lock box  under the sink.   The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F.  The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional at the time of the visit. Trash cans had tight fitting lids. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room.   There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non private bathrooms. There is  a fireplace in the living room that is properly secured. It is screened and there are no tools. 
 
The facility has emergency exit signs . 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 smoke alarm system is battery operated.  The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Fire extinguishers were observed fully charged and purchased in April 2024.
 
There is an attached garage that is only accessible to staff. The laundry area is located here as well. PPE and extra facility supplies were observed sufficiently stored.

There are cabinets located in the main hallway that stored an adequate supply of extra bed and bath linens along with toiletries and personal hygiene supplies.   Cabinets are to be locked and inaccessible to residents in care.   There is a functioning telephone on the premises.  The emergency exiting plans/sketch are posted throughout.   The emergency telephone numbers and other required postings are posted in the office area in the living room.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
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: MEDO PEACEFUL HOME
FACILITY NUMBER: 565850572
VISIT DATE: 12/06/2024
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Continued from 809-C

The exterior passageways were clean and clear of any obstructions.   There is a covered patio area in the rear of the home. LPA observed appropriate furniture for outdoor use. The outside area  was observed to be large enough to conduct outdoor activities. There is no body of water observed at this time.

Component III  was conducted in conjunction with the visit.
 
No corrections required  on a pre-licensing visit at this time. Exit interview conducted. Report issued and provided to Licensee.

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.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/06/2024
LIC809 (FAS) - (06/04)
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