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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191221767
Report Date: 08/23/2024
Date Signed: 08/24/2024 08:32:34 PM

Document Has Been Signed on 08/24/2024 08:32 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PORTER RANCH HOME #3FACILITY NUMBER:
191221767
ADMINISTRATOR/
DIRECTOR:		PARICA, EMMAFACILITY TYPE:
740
ADDRESS:8300 CAPPS AVENUETELEPHONE:
(818) 993-4376
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 6DATE:
08/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Chita Beltaran- AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Administrator, Chita Beltran and explained the reason for the visit.
At approximately 9:40 am, with the assistance of Administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were three (3) bedrooms designated for residents' use and one (1) bedroom is designated for staff' use. All three bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting.Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 111.2 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. 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 laundry area is located by the kitchen, all laundry detergents were locked.Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. LPA observed that R2 and R6 are missing updated Medical assessment. Administrator was advised to update both resident's medical assessment promptly. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.Medications: Medication and Medication Records were review for proper documentation.Temperature: Facility maintains a comfortable temperature of 77 degrees Fahrenheit. (Continue on 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PORTER RANCH HOME #3
FACILITY NUMBER: 191221767
VISIT DATE: 08/23/2024
NARRATIVE
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All smoke alarms and carbon monoxide detectors were observed to be functioning properly. The fire extinguisher is located in the kitchen with purchase date 08/23/24.

Exit interview conducted, citation issued, appeal rights given and copy of this report delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/24/2024 08:32 PM - It Cannot Be Edited


Created By: Mariana Agban On 08/23/2024 at 02:36 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PORTER RANCH HOME #3
FACILITY NUMBER: 191221767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87458(a)
Medical Assessment
(a) Prior to a person's acceptance as a resident, the licensee shall obtain and keep on file, documentation of a medical assessment, signed by a physician, made within the last year. The licensee shall be permitted to use the form LIC 602 (Rev. 9/89), Physician's Report, to obtain the medical assessment.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above. LPA observed that R2 and R6 don't have current medical assessments. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/24/2024
Plan of Correction
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The administrator agreed to email LPA updated LIC 602 by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2024


LIC809 (FAS) - (06/04)
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