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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607384
Report Date: 02/19/2025
Date Signed: 02/19/2025 04:16:52 PM

Document Has Been Signed on 02/19/2025 04:16 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CASA COSTELLOFACILITY NUMBER:
197607384
ADMINISTRATOR/
DIRECTOR:		MARIA ELENA SHINNFACILITY TYPE:
740
ADDRESS:8347 COSTELLO AVE.TELEPHONE:
(818) 892-8853
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 4CENSUS: 4DATE:
02/19/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:47 AM
MET WITH:Maria Elena ShinnTIME VISIT/
INSPECTION COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by the Administrator Maria Elena Shinn and informed them of the reason for the visit. The facility is vendored by North Los Angeles Regional Center as a level three (3) home.

The LPA and the Administrator 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.

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 extinguisher to be fully charged and last serviced on 12/24/2024. All required posting were observed throughout the facility. At 4:03 p.m., smoke alarms and carbon monoxide detectors were tested and functioning properly.



KITCHEN: The LPA observed the kitchen and dining area. 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. At 12:15 p.m., hot water measured at 105.2-degree Fahrenheit. The laundry units are located inside the kitchen. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside the locked storage cabinets.

BEDROOMS: The facility is a single-story residential home with four (4) bedrooms, three (3) for resident use and one (1) for staff use and three (3) bathrooms. Two bedrooms are private rooms and one is a shared bedroom. One bedroom has a private bathroom. The staff’s bedroom was observed to be locked and inaccessible to residents in care at the time of the visit. The bedrooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level.
Continued on LIC 809-C…
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/19/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CASA COSTELLO
FACILITY NUMBER: 197607384
VISIT DATE: 02/19/2025
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RESTROOMS: Residents’ restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. The hot water temperature tested at 105.0-degree Fahrenheit.

OUTDOOR SPACE: The patio was observed to be equipped with a table and chairs and shade for residents’ use.

RECORDS: Records review began at 1:03 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. The Administrator was reminded that the 20-hour annual trainings must be dated as the date when the trainings took place. The Surety Bond is for $5000 and expires on 01/31/2026.

Currently the facility staff is conducting drills every six (6) months. The LPA reminded the Administrator that Emergency Drill must be conducted on a quarterly basis.

MEDICATIONS: Medications review began at 3:15 p.m.; medications are centrally stored and locked in a cabinet in the kitchen; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

The LPA reviewed the following documents:


- LIC500 Personnel Roster (Administrator will email an updated form to LPA).
- LIC9020 Client Roster
- Certificate of Liability Insurance
- Emergency Drills

No deficiencies were observed at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/19/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/19/2025
LIC809 (FAS) - (06/04)
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