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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607384
Report Date: 02/11/2022
Date Signed: 02/11/2022 02:31:01 PM

Document Has Been Signed on 02/11/2022 02:31 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CASA COSTELLOFACILITY NUMBER:
197607384
ADMINISTRATOR:MARIA ELENA SHINNFACILITY TYPE:
740
ADDRESS:8347 COSTELLO AVE.TELEPHONE:
(818) 892-8853
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 4CENSUS: 3DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:50 AM
MET WITH:Maria Elena ShinnTIME COMPLETED:
02:35 PM
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At 10:50 a.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by Licensee, Maria Elena Shinn. This annual had a specific emphasis on infection control practices and procedures.

At 11:22 a.m., LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: At 11:24 a.m., LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications and first aid kits are located in a locked kitchen cabinet. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in a kitchen cabinet.

OUTDOOR SPACE: At 11:26 a.m., LPA observed the front entrance, which has a covered space for resident use. There is a gate on the side of the facility designated for an emergency exit. There is a self-latching gate at the entrance of the facility.

BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats.

Continued on LIC 809C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CASA COSTELLO
FACILITY NUMBER: 197607384
VISIT DATE: 02/11/2022
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Continued from LIC 809.

COMMON AREAS: LPA observed common area to be relatively clean and properly furnished. LPA observed the fire extinguisher to be fully charged and purchased on 01/09/2022.

STORAGE and STAFF ROOM: At 11:25 a.m., LPA observed the den, storage room and staff room. There are two (2) laundry areas in the facility, one (1) in the storage room and one (1) near the kitchen.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Between 11:05 a.m. - 2:05 p.m., LPA conducted Infection Control mitigation module with Licensee. At 2:10 p.m., LPA discussed Advisory Notes - Technical Violation with Licensee.

No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC809 (FAS) - (06/04)
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