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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608813
Report Date: 05/20/2023
Date Signed: 05/20/2023 03:49:59 PM

Document Has Been Signed on 05/20/2023 03:49 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:CASA BLANCA HOMECARE IIFACILITY NUMBER:
197608813
ADMINISTRATOR:MARIA LUISA ANDREASFACILITY TYPE:
740
ADDRESS:16411 GOTHIC PLACETELEPHONE:
(818) 363-6319
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 6DATE:
05/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:01 AM
MET WITH:Maria Andreas, Adelaida Almazan, Jomar VironTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Maria Andreas, and staff, Adelaida Almazan and Jomar Viron. They were advised of the reason for the visit.

At 11:15am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual. Smoke alarms are hardwired and interconnected. The fire extinguisher is located in the kitchen. It was purchased on 11/30/22

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in a closet by the kitchen. It requires a combination to unlock.

Bedrooms: There were six (6) bedrooms designated for residents' use. All six rooms are for private use. All six rooms were properly furnished with appropriate beddings and linens with sufficient lighting. There is also a sufficient supply of linen and towels stored in the linen closet.

Bathrooms: There are four (4) bathrooms designated for residents' use. All the bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured and it ranged between 110-117 degrees Fahrenheit. No cleaning supplies were observed accessible to residents in the bathrooms.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 05/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/20/2023
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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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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: CASA BLANCA HOMECARE II
FACILITY NUMBER: 197608813
VISIT DATE: 05/20/2023
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. There was a storage area in the backyard that was kept locked. Side gates were not locked. It was also free of obstruction. The laundry is located in the garage. There are also two refrigerators in the garage where additional perishable food is being maintained. The garage is inaccessible to the residents in care.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records are maintained and locked in a closet located near the kitchen. Medications were reviewed for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit.

Exit Interview Conducted and a Copy of this Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 05/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/20/2023
LIC809 (FAS) - (06/04)
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