191290719-2-10-2022-31-AS-MSPH-CBHTMB-20220210135052

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191290719
Report Date: 02/10/2022
Date Signed: 02/10/2022 01:52:04 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:	MOTHER GERTRUDE HOME		FACILITY NUMBER:	191290719
ADMINISTRATOR:	SR. ELIA CARO		FACILITY TYPE:	740
ADDRESS:	11320 LAUREL CANYON BLVD		TELEPHONE:	(818) 898-1546
CITY:	SAN FERNANDO	STATE: CA	ZIP CODE:	91340
CAPACITY:	97	CENSUS: 27	DATE:	02/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Sister Maria Acosta		TIME COMPLETED:	01:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	LPA Spaeth arrived to the facility and was greeted by Sister Acosta. LPA observed the COVID signs at the front door and the sign in station which contained hand sanitizer, masks, and sign in sheet. LPA's temperature was taken and LPA signed in at the sign in station. Sister Acota confirmed there are twenty seven residents at the facility. LPA and Sister Acosta began the tour at 12:00 noon. LPA observed the entrance which contains a large open room with seating for guests and residents. Upon entering the office area, LPA observed the sisters working at the facility were wearing a mask. LPA observed COVID signs posted on both the first and second floors of the building. On the way to the dining hall, LPA observed a television area where five residents were social distanced and watching television. The employee bathroom was located outside the kitchen and LPA observed wash your hands sign, hand soap, paper towels, and a trash can. LPA observed the kitchen area with two staff members preparing for lunch and both were wearing masks. LPA observed the kitchen area was clean and had been sanitized. There are two walk in cold storage refrigerators and LPA observed fresh fruits and vegetables, dairy products, juice, and other drinks. All the food within the refrigerators were properly covered. The pantry was well stocked with pasta and canned vegetables and fruits. The walk-in freezer contained various frozen meats. Sister escorted LPA to the laundry room where residents' clothing and linens are washed. The room was well ventilated and clean. The visitor bathrooms located on the first floor contained wash your hands sign, hand soap, paper towels, and a trash can.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MOTHER GERTRUDE HOME	FACILITY NUMBER: 191290719
	VISIT DATE: 02/10/2022

NARRATIVE

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LPA was escorted outside and observed a garden courtyard with comfortable seating. LPA observed four residents rooms on the first floor. The rooms are designed as a suite set up with two residents share a toilet and a shower. The toilet and shower are located in the center of the suite and have doors for privacy. The two resident rooms are on the right and left side of the bathroom area. The rooms were neat and clean and contained a bed, linens, night stand, and lamp along with resident's own personal sink.

LPA was then escorted to the second floor and observed four rooms. LPA Spaeth observed a locked storage room which contained gowns, face shields, surgical masks, gloves, hand sanitizer, and N-95 masks. The storage room also contained resident hygiene items, and the cleaning supplies. LPA observed the medication room which was locked. LPA observed the med technician was preparing the med distribution cups for the residents. LPA observed plastic bins with name of each resident on the bins.

There are no deficiencies to report at this time. Exit interview conducted, and a copy of the signed report given to Sister Acosta.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Melissa Spaeth	TELEPHONE: (818) 421-2278
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022

LIC809 (FAS) - (06/04)

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