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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609340
Report Date: 08/19/2021
Date Signed: 08/19/2021 12:31:02 PM

Document Has Been Signed on 08/19/2021 12:31 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:JACKIE'S HIDEAWAY AFACILITY NUMBER:
197609340
ADMINISTRATOR:TAL, TALYFACILITY TYPE:
740
ADDRESS:5925 DONNA AVETELEPHONE:
(818) 345-6752
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 6DATE:
08/19/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Margarita PizaTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. Upon arriving, LPA contacted the facility, and spoke to Co-Administrator Margarita Piza, who reported to LPA, there are not any active or past COVID cases at the facility. All (12) staff and (6) residents have been vaccinated. The current census is (6). LPA was greeted at the front door by the Co-Administrator Margarita, who allowed LPA to enter. LPA’s temperature was not taken, and LPA had to instruct Co-Administrator to take temperature. LPA signed in the visitor book, and observed hand sanitizer at the front door. COVID-19, CDC, Department of Public Health, and Licensing postings were observed on the walls throughout the facility. The Administrator Taly Tal, was contacted and notified of the visit and arrived at the conclusion of the inspection.

The infection control inspection began with the Co-Administrator escorting LPA throughout the facility. The facility has (6) private bedroom, and (5) bathrooms. All bedrooms were properly furnished and with clean furnishings. Common areas were observed to be clean, including bathrooms; with soap and towels and hand washing signs posted. LPA conducted a mitigation plan review with the Co-Administrator, to obtain information on how the facility has implemented the plan. The Co-Administrator reported to LPA, the facility continues to surveillance testing, by rotating staff every (3) weeks for COVID testing. The facility keeps documentation of the test results and other pertinent information pertaining to COVID-19. Administration continues to conduct training to staff in relation to COVID-19. Staff have been notified that there is a paid sick leave policy in place. PPE, chemicals, cleaning supplies, emergency food and water, personal hygiene supplies, and paper products are stored in the locked unit, located in the backyard of the facility. Perishables are also stored with (3) refrigerators stocked with food for the facility. LPA observed the facility has Licensing requirement for food supply. Currently, the facility has sufficient staff. The Co-Administrator

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/19/2021
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: JACKIE'S HIDEAWAY A
FACILITY NUMBER: 197609340
VISIT DATE: 08/19/2021
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informed LPA that they continue to implement the best practices for their facility; which has kept them COVID-19 free from residents. The facility 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 with Co-Administrator, and Licensee and copy of report was provided.

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

DATE: 08/19/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2021
LIC809 (FAS) - (06/04)
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