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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191222579
Report Date: 11/19/2024
Date Signed: 11/19/2024 06:28:19 PM

Document Has Been Signed on 11/19/2024 06:28 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:JARAVATA NORTHRIDGE HOMEFACILITY NUMBER:
191222579
ADMINISTRATOR/
DIRECTOR:		MARIA FE DEL ROSARIOFACILITY TYPE:
735
ADDRESS:9532 RHEA AVENUETELEPHONE:
(818) 882-9013
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 4DATE:
11/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
02:51 PM
MET WITH:Rachel Bangsail - House managerTIME VISIT/
INSPECTION COMPLETED:
06:30 PM
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A One (1) Required Annual visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with House manager Rachel Bangsail. Purpose of the visit was stated. This is North Los Angeles Regional Center vendored facility level 2.

At 3:10 PM, A tour of the physical plant was assessed and the following was noted:

The main door is the only entrance being utilized for entry. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

Facility has four (4) private client bedrooms. The facility has three (3) bathrooms. There is one (1) additional bedroom and one (1) bathroom is designated for staff use only. There is no body water of water in the facility.
Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at a range of 109.1°F to 114.5°F and within the required range.
Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit. (continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: JARAVATA NORTHRIDGE HOME
FACILITY NUMBER: 191222579
VISIT DATE: 11/19/2024
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(continued from LIC 809)

Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the cabinet below the kitchen sink.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is set at 75°F and observed to be within the required range.
Fire extinguisher. There is a fire extinguisher in the facility located in the living. Extinguisher was observed to be full and last bought on 02/21/24. Smoke alarms are battery operated, tested and observed to be operable. The garage is currently being used as frozen and emergency food storage, PPE, décor, and old equipment storage. The garage has access from the inside but not being utilized, only the front main garage panel. There is a tool shed in a backyard being used as tools, gardening and old equipment storage. The shed was locked during visit. The laundry room is located adjacent to the kitchen and observed to be locked, laundry soap and other toxins are kept in a cabinet inside the laundry room. Dishwashing liquid and other cleaning agents are kept locked in the kitchen cabinet below the sink.

Medication was observed to be inaccessible and stored in a secured cabinet located near the kitchen. Medication records and procedures reviewed with staff. There is a complete First Aid kit in the medication cabinet.



Client records were reviewed for current IPP and/or Needs and Service plans. Physician report, admission agreements and P & I fund. Client records appeared to be complete and current. Staff records were checked. Staff present has criminal record clearances and associated to this facility.
Staff records appear to be complete and current.

Disaster drill was last conducted on 11/01/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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