191290882-8-26-2024-31-AS-MAGN-D8HVMX-20240826163416

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191290882
Report Date: 08/26/2024
Date Signed: 08/26/2024 04:34:54 PM

Document Has Been Signed on 08/26/2024 04:34 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:	BRIGHT EYES RETIREMENT HOME #5		FACILITY NUMBER:	191290882
ADMINISTRATOR:	FABREGAS, NORMA		FACILITY TYPE:	740
ADDRESS:	19615 ROSCOE BOULEVARD		TELEPHONE:	(818) 701-9193
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 6	DATE:	08/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Norma Fabregas		TIME COMPLETED:	02:00 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	Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by staff and explained the reason for the visit. Shortly after, LPA met with Administrator Norma Fabergas. A tour of the physical plant was conducted at 10:00 AM. Common Areas: This includes the living room dining areas were appropriately furnished and lighting was adequate. Medications are locked in the dining room cabinet. Medications observed to be locked and inaccessible to residents. The living room has a television and comfortable furniture. Bedrooms: The facility has 7 bedrooms. Six (6) bedrooms designated for residents' use and (1) bedroom designated for staff. All bedrooms were clean, properly furnished and had sufficient lighting. Residents have enough personal hygiene products provided by the licensee. LPA observed enough and clean linen available in cabinets. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Sharp objects were stored in locked drawers and cabinets. LPA observed fully stocked first aid kit in the dining room cabinet. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored in kitchen pantry. LPA observed fire extinguisher to be full with inspection date 04/10/24. Temperature: Facility maintains a comfortable temperature of 75 degrees Fahrenheit. Bathrooms: There were three (3) bathrooms in the facility. Two (2) bathrooms in hallways which are the mains and One (1) bathroom in a private bedroom. All bathrooms were clean, properly supplied and had functional fixtures. Water temperatures were: 110.2 and 111.9 degrees Fahrenheit. All chemical cleaners were locked under the sink cabinet. Laundry Area: located through the kitchen. Appliances observed to be in good repair. All cabinets were locked and thus laundry detergents were inaccessible to residents. LPA observed another fire extinguisher to be full with inspection date 04/10/24. Smoke and Carbon Monoxide: detectors are hardwired, interconnected and observed to be operational. Outdoor Area: facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms. (Continue on 809C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

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: BRIGHT EYES RETIREMENT HOME #5	FACILITY NUMBER: 191290882
	VISIT DATE: 08/26/2024

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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.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 08/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/26/2024

LIC809 (FAS) - (06/04)

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