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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607384
Report Date: 02/03/2023
Date Signed: 02/03/2023 10:48:46 AM

Document Has Been Signed on 02/03/2023 10:48 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. #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: 4DATE:
02/03/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:33 AM
MET WITH:Maria Shinn, Licensee TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced required annual visit. At 9:30 a.m., the LPA met with the Licensee and explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures. The facility is vendored by North Los Angeles Regional Center as a level three (3) home.

At 9:50 a.m., the LPA along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications are centrally stored and located inside a locked cabinet in the kitchen. The laundry units are located inside the kitchen. BEDROOMS: The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Client restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 10:08 a.m., the hot water temperature tested at 118.2-degree F. OUTDOOR SPACE: At 10:01 a.m., the LPA observed the back patio which has a covered outdoor area for client use. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside the locked staff rooms. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the fire extinguishers to be fully charged and last serviced on 12/29/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 10:09 a.m., smoke alarms and carbon monoxide detectors were tested and functioning properly. INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening and temperature checks. The LPA observed a 30-day supply of Personal Protection Equipment (PPE). The facility’s policies and procedures as it pertains to infection control are adequate. No deficiencies were observed at this time. Exit interview conducted. A copy of the report was provided via email and print.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2023
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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