197608813-4-27-2024-31-AS-MCAA-D4QS5W-20240427133501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608813
Report Date: 04/27/2024
Date Signed: 04/27/2024 01:35:41 PM

Document Has Been Signed on 04/27/2024 01:35 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 II		FACILITY NUMBER:	197608813
ADMINISTRATOR/ DIRECTOR:	MARIA LUISA ANDREAS		FACILITY TYPE:	740
ADDRESS:	16411 GOTHIC PLACE		TELEPHONE:	(818) 363-6319
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY: 6		CENSUS: 4	DATE:	04/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:47 AM
MET WITH:	Kevin Caponpon,		TIME VISIT/ INSPECTION COMPLETED:	01:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Kevin Caponpon. The administrator, Maria Andreas, came to the facility shortly after. They were advised of the reason for the visit. At approximately 09:50am, 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 01/30/24. 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. There is a table at the center, that seats four (4), for staff use. Bedrooms: There were six (6) bedrooms designated for residents. All six rooms are for private use. The rooms, in use by the residents were observed to be properly furnished with appropriate beddings and linens with sufficient lighting. According to the administrator, facility is getting ready to admit a new resident tomorrow, 04/28/24. 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 112-120 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: 04/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2024

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: 04/27/2024

NARRATIVE

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There is a fireplace, which was properly screened. The fireplace is non-operable, and there were no tools present. The dinning room table is large enough to seat six (6). The sofa, chairs and table in the living room were in good repair, and the floors were clean and maintained.

Surrounding Grounds: Entry/exits were free of obstruction. There is shaded area in the backyard with furniture appropriate for outdoor use. The outdoor area was free of hazards. There was a storage area in the backyard. Currently maintenance and storage area with tools are in use, but tools and work area for maintenance are inaccessible to the residents. Maintenance had put up barricades to insure no resident access at the time work is being done. Moreover, sufficient supervision present to insure residents do not access the work area. The side gates are not kept locked, or blocked, to insure it is free of obstruction.

Garage: 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 also used for storage space to keep PPE supplies. The garage is connected to the home, but is inaccessible to the residents in care. It requires a combination code to gain access.

Resident Files: Resident files are kept in the garage. LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: Staff files are kept in cabinet in the living room area. LPA 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 and medication records were reviewed for proper documentation and system implementation. .

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: 04/27/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/27/2024

LIC809 (FAS) - (06/04)

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