197610043-4-27-2023-29-AS-SURA-CRAKJW-20230427075723

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610043
Report Date: 04/26/2023
Date Signed: 04/27/2023 07:58:21 AM

Document Has Been Signed on 04/27/2023 07:58 AM - 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:	MEGAN'S PLACE		FACILITY NUMBER:	197610043
ADMINISTRATOR:	OSBORN, ANNIE		FACILITY TYPE:	740
ADDRESS:	7708 ETHEL AVENUE		TELEPHONE:	(818) 853-7654
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 4	DATE:	04/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Annie Osborn		TIME COMPLETED:	02:59 PM

NARRATIVE

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 10:10 a.m. The LPA initially met with Administrator Annie Osborn, and discussed the reason for the visit.

The LPA, and administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: Residents' bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four (4 ) bedrooms; three (3 ) are for resident use and one(1 ) is designated as a staff bedroom.

RESTROOMS: Residents’ restrooms are clean, and in sanitary condition. Shower is equipped with grab bars and non-skid surfaces. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper product in the restroom.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The required postings were observed in the common area.

OUTDOOR: The backyard has a covered outdoor area equipped with furniture for residents’ use. There were no bodies of water noted. The garage was observed locked, and contained the laundry area, as well as emergency food supply, and storage.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable, and non-perishable food. All knives, and cleaning supplies were observed to be locked, and properly stored at the time of the visit.

Continues on LIC 809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEGAN'S PLACE	FACILITY NUMBER: 197610043
	VISIT DATE: 04/26/2023

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RECORDS: Client records review began at 11:59 a.m. Client records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

PERSONNEL: Personnel records were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 1:40 p.m.; medications are centrally stored and locked in a cabinet in the kitchen cupboard room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs discussed the new PIN changes regarding infection control.

The LPA obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Staff schedule

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 04/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/26/2023

LIC809 (FAS) - (06/04)

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