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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609306
Report Date: 10/10/2022
Date Signed: 10/10/2022 03:17:49 PM

Document Has Been Signed on 10/10/2022 03:17 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELAINE'S PLACEFACILITY NUMBER:
197609306
ADMINISTRATOR:BOTE, ELAINE PFACILITY TYPE:
740
ADDRESS:22745 DOLOROSA STREETTELEPHONE:
(818) 340-7769
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 5DATE:
10/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Elaine Bote-AdminsitratorTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA met with Licensee Elaine Bote and explained the reason for the visit. The LPA, along with staff, toured the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient food supply. BEDROOMS: Bedrooms had appropriate furniture, clean linens and sufficient lighting. Rooms were clean and clear of obstructions. RESTROOMS: The restrooms were clean and sanitary with grab bars and non-skid surfaces. Between 2:23 p.m. and 2:29 p.m., water temperature measured between 109.4 F and 110.1 F. The facility is stocked with soap and paper towels. Appropriate hand washing signs were observed. COMMON SPACES: The facility maintained a temperature of 78 degrees. Medications were locked in a cabinet in the kitchen. Smoke and carbon monoxide detectors were operable. Furniture were observed in good condition. The backyard had furniture and a covered area. No obstructions observed in the exterior or interior. The LPA interacted with the residents during the visit, whom had no concerns at the time. No bodies of water noted.

INFECTION CONTROL: There is a central entry point for screening and temperature checks. Staff were observed wearing appropriate face coverings. Infection control signs were observed on the bulletin board in the dining/living room. The facility’s cleaning protocol is sufficient. There is record of staff and resident vaccinations. The facility can designate a room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines for visitation and vaccine requirements. The facility has a sufficient supply of Personal Protection Equipment (PPE) and can obtain additional supplies. The policies and procedures pertaining to infection control were adequate.

No deficiencies cited. Exit interview conducted. Report issued.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2022
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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