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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221767
Report Date: 01/04/2022
Date Signed: 01/04/2022 03:23:33 PM

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:PORTER RANCH HOME #3FACILITY NUMBER:
191221767
ADMINISTRATOR:PARICA, EMMAFACILITY TYPE:
740
ADDRESS:8300 CAPPS AVENUETELEPHONE:
(818) 993-4376
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 5DATE:
01/04/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Chita Beltran - Assistant AdministratorTIME COMPLETED:
03:30 PM
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Licensing Program Analysts (LPAs) Tihesha Smith and Gary Tan conducted an unannounced Required 1 year visit and inspection of the facility. LPAs met with Assistant Administrator Chita Beltran. LPAs explained the reason for the visit.

A tour of the physical plant was conducted at 11:00 AM. All smoke alarms and carbon monoxide detectors were tested and observed to be functioning properly. The fire extinguishers were observed to be full and current.
Kitchen: The kitchen appeared clean and appliances and fixtures functional. Laundry detergents, cleaning agents and other toxins are kept in a locked cabinet below the sink. Knives and sharps were stored in locked drawers. Laundry room is located adjacent to the kitchen on the way to the yard. Properly labeled medications were locked in a cabinet in the kitchen. Bedrooms: There were three (3) bedrooms designated for residents' use. One (1) additional bedroom is designated for staff use. All bedrooms were clean, properly furnished and had sufficient lighting. Bathrooms: There were two (2) bathrooms designated for residents' use. Both bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was 113.3 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction.There is a shed in the backyard being used as a used equipment storage. The shed was observed to be locked. There is no body of water in the facility. The outdoor area was clean and free of hazards.
LPAs reviewed files present staff and residents. All resident files included current medical assessments, physician orders for medications and centrally stored medication logs. Medications are given as prescribed. Staff schedule appears sufficient to meet the needs of residents.

Exit interview conducted. Copy of this report issued.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 01/04/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/04/2022
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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