191222589-12-11-2023-31-AS-LNCA-CYEU9B-20231211142251

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191222589
Report Date: 12/11/2023
Date Signed: 12/11/2023 02:22:59 PM

Document Has Been Signed on 12/11/2023 02:22 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HINOJOSA ADULT RESIDENTIAL HOME CARE		FACILITY NUMBER:	191222589
ADMINISTRATOR:	HINOJOSA, CLAUDIO & OLGA		FACILITY TYPE:	735
ADDRESS:	10736 STAGG STREET		TELEPHONE:	(818) 764-7184
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY: 4		CENSUS: 4	DATE:	12/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Olga Hinojosa- Licensee		TIME COMPLETED:	02:30 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) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. Olga Hinohoja who is the licensee met with LPA, explained the reason for the visit. Approximately, around 12:30pm Carlos Hinojosa who is the administrator arrived. At 12:30 pm, with the assistance of administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, exercise room and in between kitchen and staff room. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the office and between kitchen and staff room. The charge date is 8/22/2023. During the visit the facility is at 68 degrees Fahrenheit. The facility is fire cleared for four (04) ambulatory residents. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Bedrooms: There were six (6) bedrooms designated for residents' use. Room #1 and room #2 two (2) of the bedrooms that are shared, is used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Room #3 is an exercise room that is located at the end of the hallway. Room #4 is a storage room that is located in the kitchen that is used for PPE storage. Room #5 and room #6 is for staff bedroom is locked with no medication in sight. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: HINOJOSA ADULT RESIDENTIAL HOME CARE	FACILITY NUMBER: 191222589
	VISIT DATE: 12/11/2023

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Bathrooms: There are one (1) bathroom designated for residents' use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 119.8 degrees Fahrenheit for bathroom #1 located in the hallway beside room #1 and and across #2. Bathroom #2 is beside staff room. Cleaning supplies are being stored in a locked cabinet in the laundry room that is located outside of the kitchen. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for four (4).

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area and detergents are located by the laundry area and are kept secured. The facility does not have a swimming pool or body of water. The garage is a port and is used for parking.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is across the dining area beside the kitchen by the entrance.

Medications: Medication and Medication Records (MMR) were review for proper documentation. Properly labeled medications were locked in the cabinets in the office station.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit interview conducted and a copy of the report issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 12/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/11/2023

LIC809 (FAS) - (06/04)

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