197610405-4-24-2023-31-AS-ADUA-CR7TMS-20230424145139

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610405
Report Date: 04/24/2023
Date Signed: 04/24/2023 02:52:26 PM

Document Has Been Signed on 04/24/2023 02:52 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:	A HUMBLE ABODE INC		FACILITY NUMBER:	197610405
ADMINISTRATOR:	BUNGABONG, SILICA		FACILITY TYPE:	740
ADDRESS:	25703 WHISPERING TREES WAY		TELEPHONE:	(818) 428-5352
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY: 6		CENSUS: 0	DATE:	04/24/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	James Contreras, Licensee		TIME COMPLETED:	02:50 PM

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Licensing Program Analyst (LPA) Abeye Duguma conducted an announced Pre-licensing visit at 10:00 AM and met with the Licensee, James Contreras. LPA conducted an entrance interview with the Licensee. LPA Duguma also observed that there were no residents during the inspection. All residents appear to be clean and groomed.

With the assistance of the Licensee, LPA conducted a facility Tour of both the inside and outside. This is a single-story property. Fire Clearance is approved for six (06) non-ambulatory of which one (01) may be bedridden. Facility has five (05) bedrooms and two (02) full bathrooms. One (01) out of five (05) bedrooms is semi-private and the remaining are all private single occupancy. All residents’ bedrooms were adequately furnished. The facility has a designated as a staff room/office. Resident bathrooms have properly installed grab bars and shower has non-skid mats. The average hot water temperature measured at 117.3ºF during the visit.

The common areas were appropriately furnished. The LPA observed entertainment equipment and games for activities. The has a designated storage cabinet for residents and staff records located near the kitchen and dining area. The first-aid kit is complete. The facility has adequate linen, water, and emergency kits. The linens were stored in the storage space located in the hallway.

(CONT. on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: A HUMBLE ABODE INC	FACILITY NUMBER: 197610405
	VISIT DATE: 04/24/2023

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LPA observed a fireplace that was permanently blocked with the locked screen. The facility has working egress alarms on all exits. Smoke detectors and Carbon Monoxide detectors were checked and function properly. There are fully charged fire extinguishers located in the kitchen area and hallway. Receipt shows that fire extinguishers were purchased on 01/09/2023 and LPA advised the Licensee to retain the receipt of the fire extinguisher identifying the purchase date to ensure the time frame for annual inspection.

LPA Duguma observed a washer and dryer in the laundry room adjacent to the garage. All chemicals, additional personal hygiene items were stored in the garage. The medications are stored in a locked cabinet located near the kitchen and dining area.

LPA inspected the kitchen and observed stove and refrigerator to be clean and working. Knives and sharps are stored in a locked kitchen drawer.

There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

At the time of this visit the physical plant is meeting Title 22 requirements.

Component III was completed with the LPA.

No health and safety hazard were noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2023

LIC809 (FAS) - (06/04)

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