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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610253
Report Date: 12/14/2024
Date Signed: 12/14/2024 03:49:28 PM

Document Has Been Signed on 12/14/2024 03:49 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:ASSURECARE HOME INCFACILITY NUMBER:
197610253
ADMINISTRATOR/
DIRECTOR:		PELEGRINO, FLORENCE CFACILITY TYPE:
740
ADDRESS:16729 TULSA STTELEPHONE:
(747) 239-3219
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 5DATE:
12/14/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:49 AM
MET WITH:Adele CahayonTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Adele Cahayon, and explained the reason for the visit.

At approximately 12:00pm, with the assistance of staff, LPA took a tour of the physical plant. The facility is a one story building. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual and interconnected. The fire extinguisher is located between the entrance and kitchen. It was charged on July 3, 2024.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The laundry room is located adjacent to the kitchen. No cleaning supplies observed during inspection.

Bedrooms: There are five (5) bedrooms, of which four (4) is used for residents and one (1) is a staff room. The bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured between 107 to 110 degrees Fahrenheit. Cleaning supplies were stored and locked.

Common Areas: These included the living room and dining area. The living room is furnished with two couches, two recliners and a television. The table in the dining room is large enough to seat six (6)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/14/2024
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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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: ASSURECARE HOME INC
FACILITY NUMBER: 197610253
VISIT DATE: 12/14/2024
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residents. There is also additional seating in the dining room area. The floors were mopped and clean. LPA observed furniture to be maintained and in good repair. Exit/entrance and passageways were clear of obstruction. The auditory alarms on all exit doors were on and functional at the time of the visit.

Surrounding Grounds: Pathways in the front and backyards were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards.

Laundry Room: The laundry room is located adjacent to the kitchen. Detergents and cleaning supplies were observed inside the laundry room. Laundry room was locked during the visit.

Garage: The garage is attached to the home. It is used as additional storage space. No resident access

Staff Work Station: Staff work station is located next to the dining room. There is a cabinet where both resident and staff records are filed.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure compliance with licensing forms.

Medications: Medications are are stored locked in one of the kitchen cabinets. Medication and Medication Records were review for proper storage and documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 12/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/14/2024
LIC809 (FAS) - (06/04)
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