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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191290882
Report Date: 09/15/2023
Date Signed: 10/12/2023 08:44:52 AM


Document Has Been Signed on 10/12/2023 08:44 AM - 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 #5FACILITY NUMBER:
191290882
ADMINISTRATOR:FABREGAS, NORMAFACILITY TYPE:
740
ADDRESS:19615 ROSCOE BOULEVARDTELEPHONE:
(818) 701-9193
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 6DATE:
09/15/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Norma Fabergas- AdministratorTIME COMPLETED:
02:05 PM
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On 09/15/23 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 11:15AM.
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 and dated on 04-24-2023. 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: 116.2,115.3,117.2 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 and dated on 04-24-23.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.

No deficiencies issued during today’s visit. Report was signed and delivered and an exit interview was conducted

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 09/15/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/15/2023
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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