197608341-8-29-2022-31-AS-NRED-CHRVN4-20220829163431

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608341
Report Date: 08/29/2022
Date Signed: 08/29/2022 04:34:39 PM

Document Has Been Signed on 08/29/2022 04:34 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BALCOM HOME		FACILITY NUMBER:	197608341
ADMINISTRATOR:	MERCEDE SHAMLO		FACILITY TYPE:	735
ADDRESS:	7767 BALCOM AVE		TELEPHONE:	(818) 342-1001
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY: 4		CENSUS: 4	DATE:	08/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:07 PM
MET WITH:	Mercede Shamlo		TIME COMPLETED:	04:45 PM

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At 2:07 p.m. on 08/29/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

It is a single story building with 4 bedrooms, 2 bathrooms, kitchen, garage, common areas, office, and outdoor areas. It has an approved fire clearance for 4 nonambulatory residents, of which 1 may be bedridden in Bedroom #2.

At the front door, the facility posted a sign for its masking policy. LPA observed a staff shift change in which Administrator screened incoming staff for infectious diseases. LPA was screened for infectious disease upon entry. The screening station contained surgical masks, N95 masks, hand sanitizer, digital thermometer, and visitor log. Staff use a storage system for their outside shoes and house shoes. Facility postings included personal rights, confidential complaint contacts, facility sketch, emergency disaster plan, house rules, and COVID precautions. Emergency supplies and water were stored near the kitchen.

The facility has 4 private bedrooms. All bedrooms contained a chair, nightstand, storage, and bed with adequate bedding. All furnishings were clean and in good condition. The facility has 2 bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash cans with tight fitting lids, grab bars near the toilet and shower, shower chairs, and a non-skid mat in the shower. LPA observed an adequate supply of perishable and non-perishable food in the kitchen and in the garage. Kitchen appliances were clean and functional. Sharps and cleaning solutions were locked under the sink. The garage was locked and contained an extra refrigerator and freezer, paper supplies, incontinence supplies, and PPE. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 2:48 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. A fireplace in the living room was inaccessible and covered appropriately. Clients and staff were doing activities in the living room during the visit. Toys, games, art materials, and television were provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

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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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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BALCOM HOME	FACILITY NUMBER: 197608341
	VISIT DATE: 08/29/2022

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An office at the end of the hallway was locked and contained client and staff files. All emergency exit paths were free from obstructions. Exit gates were unlocked with inward facing latches. At 2:50 p.m. Administrator tested the dual-function smoke and carbon monoxide detector to be operational. Detectors are hardwired. At 2:51 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 08/052022. LPA and Administrator reviewed the most recent fire drill conducted on 08/28/2022. A fully stocked First Aid kit was kept in the medication cabinet. 7 out of 7 auditory alarms were on and functional. All medications were locked near the kitchen. A covered patio in the backyard contained furniture and exercise equipment in good repair. Yards were maintained.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 08/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2022

LIC809 (FAS) - (06/04)

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