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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606778
Report Date: 03/08/2022
Date Signed: 03/08/2022 03:34:07 PM

Document Has Been Signed on 03/08/2022 03:34 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:KIND COMPANIONS HOME CAREFACILITY NUMBER:
197606778
ADMINISTRATOR:EDELWINA CALICAFACILITY TYPE:
740
ADDRESS:1225 DOROTHY DRIVETELEPHONE:
(818) 956-8744
CITY:GLENDALESTATE: CAZIP CODE:
91202
CAPACITY: 6CENSUS: 6DATE:
03/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Administrator Edelwina CalicaTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Nune Margaryan conducted an annual required visit. LPA met with Administrator Edelwina Calica who assisted with the visit. Reason for the visit was explained. LPA used the infection control tool to evaluate the facility. LPA inspected the physical plant, COVID-19 procedures, reviewed residents' medications, observed food supply, and reviewed resident and staff files. The facility is licensed for six (6) residents over the age of 60, with a hospice waiver for one (1) residents.

There is only one entrance being utilized at the facility, all required posters were posted at the entrance. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

LPA inspected the interior and the exterior of the facility with Administrator Edelwina Calica including but not limited to: living room, dinning room, kitchen, breakfast nook, laundry area in the back of the kitchen, three (3) resident bedrooms, two (2) bathrooms, covered deck, backyard and garage. All indoor and outdoor passageways are free of obstruction. No large body of water observed.

Bathrooms and bedrooms were clean and in good repair. There is a locked storages for medications in the kitchen and toxins were locked in the garage. The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. Kitchen knives and sharps are stored in a locked drawer in the kitchen. The common areas including the living room and dining room are clean and have the required furniture.

Continue on 809C

SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2022
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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME: KIND COMPANIONS HOME CARE
FACILITY NUMBER: 197606778
VISIT DATE: 03/08/2022
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Residents bedrooms were toured. Each bedroom has a smoke detector, bed, linen, dresser, light, and sufficient closet space. Both bathrooms were toured and were observed to be clean, operational and equipped with grab bars and non-skid mats / materials. The hot water was 115.2 degrees which is within the required 105 - 120 degrees.

All exit doors were alarmed and smoke detector was observed to be working properly. LPA observed 3 fire extinguishers throughout the facility which were fully charged. First-aid kit is complete and located in the living room.

LPA reviewed residents files to confirm emergency contact is updated. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared. Residents' medications were reviewed. Medications are documented properly and stored appropriately.



Based on California Code of Regulations, Title 22, there were no deficiencies observed during the visit. A copy of the report was provided to the Administrator.
SUPERVISORS NAME: Wei Siew Ho
LICENSING EVALUATOR NAME: Nune Margaryan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022
LIC809 (FAS) - (06/04)
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