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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607287
Report Date: 11/29/2022
Date Signed: 11/29/2022 10:55:18 AM

Document Has Been Signed on 11/29/2022 10:55 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:AD & T GROUP HOMEFACILITY NUMBER:
197607287
ADMINISTRATOR:TAIWO FASHOLAFACILITY TYPE:
735
ADDRESS:16815 SUPERIOR STREETTELEPHONE:
(818) 830-5813
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
11/29/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Taiwo FasholaTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA), Patrick Shanahan, arrived at the facility in order to conduct an infection control annual. The LPA was greeted by the facility administrator. The LPA had his temperature taken at the door and was asked all Covid -19 questions.

The home consists of 4 bedrooms for residents and one bedroom for staff. There are 2 bathrooms for the residents use. The smoke alarms and carbon monoxide detectors were tested and functioned properly. A fire extinguisher was observed in the kitchen and appeared functional.

The facility is currently following their infection control plan and no deficiencies were observed during todays visit.

Exit interview conducted and report issued.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Patrick Shanahan
LICENSING EVALUATOR SIGNATURE: DATE: 11/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/29/2022
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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