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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610155
Report Date: 07/23/2024
Date Signed: 07/23/2024 01:23:57 PM

Document Has Been Signed on 07/23/2024 01:23 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MAMELEH & TATELEH'S UPSCALE LIVINGFACILITY NUMBER:
197610155
ADMINISTRATOR/
DIRECTOR:		CHO, DANIEL D.FACILITY TYPE:
740
ADDRESS:18847 THORN CREST COURTTELEPHONE:
(213) 392-2325
CITY:SANTA CLARITASTATE: CAZIP CODE:
91351
CAPACITY: 6CENSUS: 5DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Irma Parchejo & Daniel ChoTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted annual inspection. LPA was greeted by caregiver Irma Parchejo, who allowed LPA to enter. Administrator Daniel Cho was notified and arrived shortly after. LPA observed COVID signs outside the front door, and upon entry, several more signs, with a hand washing station, sign in sheet, and electronic thermometer. Licensing signs and postings located throughout the facility on the walls.

A physical plant inspection of the inside and outside was conducted with LPA and caregiver Irma.

Kitchen: LPA observed Licensing requirement of (7) day nonperishable, and (2) perishable, with extra refrigerator and freezer located in the garage area; stocked with food. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, knives, and hygiene products, were locked and secured located in the garage. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (5) bedrooms for residents; with (1) shared, and (4) private. All bedrooms were properly furnished and supplied with appropriate bedding and linens. There were sufficient linens observed and available. Bathrooms: There are (3); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured at 114.8 degrees Fahrenheit. Surrounding Grounds: The facility has outdoor furniture, for resident's comfort. There are no swimming pools or bodies of water. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the laundry room. All exit doors have alarms and were operating properly. Fire extinguisher fully charged. First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors were tested and operating properly.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2024
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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Document Has Been Signed on 07/23/2024 01:23 PM - It Cannot Be Edited


Created By: Tuesday Cabiness On 07/23/2024 at 11:26 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MAMELEH & TATELEH'S UPSCALE LIVING
FACILITY NUMBER: 197610155

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, staff #1 & staff # 2, did not have current first aide/CPR certificates. Records showed they expired March 2024. This poses as a potential health and safety risk to residents in care.
POC Due Date: 07/26/2024
Plan of Correction
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Licensee AGREED to submit current first aide certificates to LPA by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024


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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MAMELEH & TATELEH'S UPSCALE LIVING
FACILITY NUMBER: 197610155
VISIT DATE: 07/23/2024
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Record review: A complete record review of staff and residents were conducted. Staff # 1 and 2, are missing current first aide/CPR certificates; expired March 2024. Training records were current; and medication records were reviewed with no errors. All resident's files were current with Licensing documents.

Citation issued, appeal right, exit interview, and copy of report provided...

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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