197610453-10-5-2024-31-AS-JGTN-D9RQGY-20241005121019

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610453
Report Date: 10/05/2024
Date Signed: 10/05/2024 12:10:58 PM

Document Has Been Signed on 10/05/2024 12:10 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:	ASAGAO HOME CARE		FACILITY NUMBER:	197610453
ADMINISTRATOR/ DIRECTOR:	MAKINOSE, ANNE LOUISE		FACILITY TYPE:	740
ADDRESS:	45701 17TH ST. W		TELEPHONE:	(213) 294-8188
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93534
CAPACITY: 6		CENSUS: 2	DATE:	10/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:10 AM
MET WITH:	Jeorge Makinose - Co Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA\) Gary Tan conducted an unannounced Required One (1) year visit at this facility. LPA met with co Administrator Jeorge Makinose and explained the reason for the visit. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. The screen door however has a broken handle. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside and inside. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area upon entrance. The facility has sufficient stock of PPE in the storage room. At 9:42 AM, tour of the physical plant was conducted with the co Administrator. This facility is a single storey house and has five (5) bedrooms and two (2) bathrooms currently occupying two (2) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, one (1) of which may be bedridden in Room #1, hospice waiver for three (3) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. The smoke detector is hardwired, tested and observed to be operational. There is a fire extinguisher located in the kitchen and observed to be full and last checked on 01/08/24. There is carbon monoxide detector installed at the facility. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2024

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASAGAO HOME CARE	FACILITY NUMBER: 197610453
	VISIT DATE: 10/05/2024

NARRATIVE

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The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. The Laundry room is located on the way to the garage. Laundry detergent and other cleaning agent are kept in a locked cabinet in the garage. Laundry room was observed to be locked during visit. The garage is also being used as frozen food, old equipment and other supplies storage.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, laundry detergents, pesticides or toxins were stored in the kitchen cabinet and observed to be locked and inaccessible to residents. All sharps and knives were also observed to be locked in a kitchen drawer.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit to non-private rooms. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: Staff room was also being used as an office. No medications are observed in the staff room.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 106.8°F to 108.7°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.

Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There are two (2) complete first aid kits located in the medication cabinet.

Client and Staff records all residents and staff present records were reviewed. Residents and staff record appeared to be complete and updated.

Disaster drill was last conducted on 08/24/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/05/2024

LIC809 (FAS) - (06/04)

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