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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191201168
Report Date: 09/19/2024
Date Signed: 09/19/2024 06:49:52 PM

Document Has Been Signed on 09/19/2024 06:49 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VILLA SCALABRINI RETIREMENT CENTERFACILITY NUMBER:
191201168
ADMINISTRATOR/
DIRECTOR:		ADILSO LUIZ BALENFACILITY TYPE:
740
ADDRESS:10631 VINEDALE STREETTELEPHONE:
(818) 768-6500
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 130CENSUS: 75DATE:
09/19/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Alicia Avila, assistant administratorTIME VISIT/
INSPECTION COMPLETED:
01:28 PM
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Licensing Program Analyst, (LPA) Leizl de la Cerra, made an unannounced site visit to this facility as a continuation of the Required 1 Year Annual Inspection conducted on 09/04/2024. LPA met with assistant administrator, Alicia Avila, and the purpose of visit was disclosed.

The following remaining inspection domains were observed, reviewed and inspected:

Medications: Residents medication are centrally stored in the medication room which is inaccessible to residents. Three (3) centrally stored resident medications were reviewed; containing 30-day supply of medications. First Aid kit complete.

Common Areas: Activity rooms, dining room and gym room observed to be clean. Furnishings observed to be in good condition. No obstructions, nor tripping hazards observed.

Laundry Rooms: LPA observed all three 3 laundry rooms throughout the facility. Residents have access to do their own laundry. Laundry area is clean and clear from obstruction. Cleaning supplies, and other toxins, are securely stored and inaccessible to residents.

Outdoor: There is large sitting area located at the back of the facility observed to have more than adequate shade, with sufficient tables and seats for the residents. There are also 10 smaller sized patio area with sufficient shade and seating for residents. All outdoor furniture observed to be in good condition. There are no bodies of water in the facility.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Leizl De La Cerra
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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