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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608905
Report Date: 09/15/2022
Date Signed: 09/15/2022 01:14:34 PM

Document Has Been Signed on 09/15/2022 01:14 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:MY HOME IIFACILITY NUMBER:
197608905
ADMINISTRATOR:MARK YULEFACILITY TYPE:
740
ADDRESS:6753 ESTEPA DRIVETELEPHONE:
(661) 219-4906
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY: 6CENSUS: 6DATE:
09/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Mark YuleTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced infection control inspection/visit. Upon arriving, LPA was greeted by the caregiver JoJo, who contacted the Administrator Mark Yule, who arrived shortly after. There have not been any active or past COVID cases at the facility, and all (6) residents and (5) staff are vaccinated and have booster shots. The current census is (6). COVID-19, CDC, Department of Public Health, and Licensing postings and hand sanitizing stations were visible seen and posted on the walls throughout the facility.

The infection control inspection began with the Administrator Mark. The facility has (6) private rooms and (3) bathrooms. Each room has it's own exit door. The common areas were observed to be clean, including resident rooms, and bathrooms. Soap and towels, and hand washing signs were visually posted. The facility has been COVID free since the pandemic, due to resident rooms having exit doors and family and friends visit outside, with the door open, social distancing and wearing a mask. Any visitor that works in a high risk environment, such as medical staff, will be given a rapid COVID test before entry.

The Administrator has documentation of all vaccination records and other pertinent information pertaining to COVID-19, in staff and resident files. All new employee hires must be vaccinated and properly screened prior to entering the facility. If there are any signs or symptoms from residents or staff, the facility has a rapid test kits in place. Administrator receives departmental emails. Sick leave policy available for staff. The facility does not have staffing issues. There are designated rooms for potential positive COVID residents because the facility has private rooms.

PPE supplies were inspected. Administrator continues to implement the best

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MY HOME II
FACILITY NUMBER: 197608905
VISIT DATE: 09/15/2022
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practices for the facility; to ensure the health and safety of residents and staff.

Administrator is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted and copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2022
LIC809 (FAS) - (06/04)
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