191201168-9-4-2024-31-AS-LDLC-D8T6U3-20240904210627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191201168
Report Date: 09/04/2024
Date Signed: 09/04/2024 09:08:33 PM

Document Has Been Signed on 09/04/2024 09:08 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: 75	DATE:	09/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Alicia Avila, assistant administrator		TIME COMPLETED:	05:15 PM

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On 09/04/2024, Licensing Program Analyst (LPA) Leizl de la Cerra conducted an unannounced annual inspection. LPA met with assistant administrator, Alicia Avila and disclosed the reason for the visit.

There are currently 75 residents who reside at this facility. This facility has a hospice waiver for 6 residents. At approximately 1:00pm, administrator toured the facility with LPA. In the assisted living unit area, LPA inspected one (1) vacant resident bedroom, kitchen, dining area, 2 activity rooms, a guest room for families, a chapel and a gym.

Fire extinguishers are located all throughout the facility and were last serviced 08/08/2024. Fire Drill was last conducted on 7/22/2024. Fire alarms, smoke detectors and carbon monoxide detectors observed through out the facility and were recently tested on 8/28/2024.

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.

Resident bedrooms and bathrooms: Bathrooms and bedrooms were clean and in good repair. LPA observed clean beds, lamp, night stand, chair and a desk with a desk chair. Hot water temperature was tested in vacant resident bathrooms and ranged from 106.7 degrees F - 113.7 degrees F. Emergency alert system checked and observed operable during visit. System is with an audio intercom where staff can communicate with resident when alert system is activated from residents room for any reason.

Continued to LIC809C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La Cerra	TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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

FACILITY NAME: VILLA SCALABRINI RETIREMENT CENTER	FACILITY NUMBER: 191201168
	VISIT DATE: 09/04/2024

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Memory Care Unit: This facility has a Memory Care section within the assisted living unit. Inside the Memory Care section, LPA observed the activity area, dining area and one (1) resident room out of ten (10) resident rooms. Memory Care section currently have 10 residents with dementia, there are a total of 3 caregivers for each eight (8) hour shift. All doors for backyard access are equipped with an operational bell/buzzer system to alert staff when door is being opened.

At 12:00pm to 1:00pm and 2:30pm to 4:00pm LPA conducted a facility files review, program plan, infection control plan, liability insurance, surety bond, emergency/disaster plan, fire clearance review, fire drill report and fire alarm/carbon monoxide report.

Surety bond effective on 2/05/2024. Liability insurance policy expires on 6/15/2025.

Resident/Staff File Review: LPA reviewed records of eight (8) random residents file and eight (8) staff files.

Due to time constraints LPA was unable to complete the Required 1 year visit. Alicia Avila was informed that a follow up visit will be made to complete the required annual visit

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Leizl De La Cerra	TELEPHONE: (818) 454-0632
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

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