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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609909
Report Date: 12/28/2022
Date Signed: 12/28/2022 02:34:49 PM

Document Has Been Signed on 12/28/2022 02:34 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:SKY LIGHT RESIDENTIAL CAREFACILITY NUMBER:
197609909
ADMINISTRATOR:PODRUMYAN, MAROFACILITY TYPE:
740
ADDRESS:19856 MAYALL STREETTELEPHONE:
(818) 945-8301
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY: 6CENSUS: 4DATE:
12/28/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Maro Podrumyan TIME COMPLETED:
02:40 PM
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On 12/28/22 Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced annual inspection. Upon arrival LPA met with administrator and the purpose of the visit was explained.
A physical plant tour was conducted at 1:25 p.m and the following was observed:

Infection Control: Covid-19 infection signage was observed inside in the common areas. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medication are centrally stored in a locked closet. Chemicals are stored under the kitchen sink and are locked. Smoke detectors/carbon monoxide are located throughout the facility and are dual hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 2:10 p.m. and appear to be functional. Facility has fire doors for all of the resident’s room. Fire doors were operational when fire alarm was tested. Fire extinguisher was observed to be charged with a service date of 06/05/22. Common Areas: All common areas were observed to be clean and properly furnished. Laundry area is located near the kitchen area. Resident Rooms: Facility has five (5) bedrooms of which one is designated for staff use. All five (5) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are three and a half (3.5) bathrooms in the facility. LPA observed all bathrooms to be cleaned. The hot water was tested and measured 110.1 F, which is in regulation. Grab bars and non-skid mats were observed. Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. Facility has a body of water that is gated and locked. LPA observed both gates with a padlocked. Facility has an attached ADU in where the Licensee resides. This ADU is only accessible through the outside of the home.

No deficiencies cited at this time. Exit interview conducted. Report signed and delivered

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/28/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/28/2022
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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