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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221159
Report Date: 12/22/2022
Date Signed: 12/22/2022 10:29:36 AM

Document Has Been Signed on 12/22/2022 10:29 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:MAHARLIKA HOMESFACILITY NUMBER:
191221159
ADMINISTRATOR:GARDOSE, NOELLIE L.FACILITY TYPE:
740
ADDRESS:17843 CANTARA STREETTELEPHONE:
(818) 343-3936
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 4CENSUS: 3DATE:
12/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:10 AM
MET WITH:Noellie LedesmaTIME COMPLETED:
10:35 AM
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At approximately 9:10 a.m. on 12/22/2022, 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.The facility was last visited on 11/14/2019 for a case management visit. It is a single story building with 5 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 4 nonambulatory residents. Approved hospice waivers for 2. LPA observed signs posted at the front for the facility’s visitation and masking policies. LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer, visitor log, masks, N95 masks, hand sanitizer, gloves, and sanitizing wipes. Additional postings inside included confidential complaint contacts, ombudsman contacts, emergency disaster plan, facility sketch, license, house rules, personal rights, and COVID precautions. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 9:34 a.m. LPA measured the room temperature to be 75 degrees Fahrenheit. The facility had 5 private bedrooms. One bedroom served as the staff room. The staff room was clean and free of hazards. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. The facility had 2 bathrooms. All bathrooms contained liquid soap, paper towels, bidets, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 9:29 a.m. LPA measured the water temperature in the resident bathroom to be 108.3 degrees Fahrenheit. LPA observed an adequate supply of perishable and non-perishable food. The stove hood was clean and surfaces were sanitary. Sharps and cleaning solutions were locked below the sink. The laundry room was adjacent to the staff room. Detergents were locked above the appliances. A fire extinguisher hung near the appliances. It was fully-charged and last serviced on 05/20/2022. All emergency exit paths were free from obstructions. Exit gates were unlocked. At 9:51 a.m. staff tested the living room smoke detector to be operational. At 9:35 a.m. LPA tested the carbon monoxide detector to be operational. The outside area contained gardened spaces and cages for pet finches. The front yard contained a covered patio area with furniture in good condition.During today's inspection, the facility is in compliance with Title 22 regulations. Exit interview conducted. Copy of report provided.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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