191201168-12-20-2023-31-AS-CALH-CYQ4EN-20231220180236

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191201168
Report Date: 12/20/2023
Date Signed: 12/20/2023 06:03:47 PM

Document Has Been Signed on 12/20/2023 06:03 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLA SCALABRINI RETIREMENT CENTER		FACILITY NUMBER:	191201168
ADMINISTRATOR:	ADILSO LUIZ BALEN		FACILITY TYPE:	740
ADDRESS:	10631 VINEDALE STREET		TELEPHONE:	(818) 768-6500
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	130	CENSUS: 73	DATE:	12/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Administrator Ardy Afshar & Co-Administrator Alicia Avila		TIME COMPLETED:	05:00 PM

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On 12/20/20/23 at around 10:00 AM Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – 1 Year Inspection to Villa Scalabrini Retirement and Special Care Unit and met with Co-Administrator Alicia Avila and Administrator Ardy Afshar. LPA was greeted upon arrival and screened for COVID-19 symptoms. Screening area is located immediately upon entrance.

The facility is a single-story building.

There are currently 73 residents who reside at this facility. This facility has a hospice waiver for 1 resident. LPA conducted a tour of the facility with the assistance of Ms. Avila between 11:00AM to 12:15PM. This facility has a memory care area within the assisted living unit. LPA inspected the interior and the exterior of the facility including the common living spaces, 10 resident bedrooms, 10 bathrooms, kitchen, dining area, activity room, library, family gathering and medication room and multi-purpose room.

All indoor and outdoor passageways/exits were free of obstruction. There is no body of water in the facility. The facility maintains a comfortable temperature at 74°F. The facility's smoke alarms are hard wired and interconnected and back up and tests are done in house on a regular basis. The facility is equipped with sprinkler system which was last tested on 01/19/23. Facility is also equipped with microphone system throughout the entire facility. This Facility also has a call signal system. LPA tested call button. Call system is triggered in Administrators Office and Medication Room. Fire extinguishers are located all throughout the facility and were last serviced 08/22/2023. Fire Drill was last conducted on 10/26/23.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient supply of perishable and non-perishable food and properly stored at the facility. Knives, cleaning agents, and other potentially hazardous items were locked and inaccessible. Kitchen has three (3) industrial refrigerators, one (1) walk-in freezer, and Two (2) pantries. All kitchen foods are labeled and dated.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

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

FACILITY NAME: VILLA SCALABRINI RETIREMENT CENTER	FACILITY NUMBER: 191201168
	VISIT DATE: 12/20/2023

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(Contd. from LIC 809)

Bedrooms: LPA inspected random resident rooms. The resident bedrooms were properly furnished with one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms: LPA observed all bathrooms to be clean, properly supplied and equipped with functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. There are four (4) common shower rooms in the facility, all observed to be clean and in good repair. Hot water was measured in random bathroom at the range of 112.5°F to 117.9°F and observed to be within the required limit. LPA observed all facility restrooms are equipped with hand washing signage and cleaning schedule.

Common Areas: These includes the living room, dining room and outdoor areas. Facility common areas appeared to be clean and appropriately furnished at the time of this visit, no accessible hazards were observed.

Medications: LPA met with medical technician Elias Larios and toured the Medication Room facility medications. The Medication room was observed to be locked at the time of visit. There are two (2) sets of first aid kit in the Medication room. LPA randomly inspected medication log all resident medications are documented and labeled and placed inside a resident cubby hole.

At 2:00pm LPA conducted a facility file review

Resident/Staff File Review: LPA reviewed records of ten (10) random residents and six (10) staff. Resident and staff records appeared to be complete and updated.

Laundry room located in the hallway no, 2 observed to be locked during visit.

There is no immediate health and safety hazard during this visit.

Pursuant to Title 22 Division 6 of the CA Code of Regulations,

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued to Administrator Ardy Shafar & Co- Administrator Alicia Avila.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2023

LIC809 (FAS) - (06/04)

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