195850101-11-10-2020-29-AS-EMIR-BV8RRX-20201110121552

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850101
Report Date: 11/10/2020
Date Signed: 11/10/2020 12:16:00 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COLONY - VALLEY GLEN 4, THE		FACILITY NUMBER:	195850101
ADMINISTRATOR:	LAU, MARISSA		FACILITY TYPE:	740
ADDRESS:	6245 MATILIJA AVENUE		TELEPHONE:	(818) 780-4804
CITY:	VALLEY GLEN	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 6	DATE:	11/10/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Marissa Lau		TIME COMPLETED:	12:30 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) Eva Miller conducted a Pre-Licensing Inspection with Administrator Marissa Lau. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with the use of "FaceTime". An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 4/22/20. A Fire Clearance was approved for a maximum capacity of six (6) residents, all of which may be bedridden, on 09/11/20. The facility is currently operating as SHALEV SENIOR LIVING 4 - 197609330 and licensed to "Esther Senior Homes Inc.". The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Valley Glen, CA. A tour of the physical plant was conducted and the following observed: KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient perishable food to accommodate a maximum capacity of six (6) residents for a minimum of two (2) days. There was sufficient nonperishable food to accommodate a maximum capacity of 6 residents for (seven) 7 days. Hot water delivered at 118F. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 Residents. The medication cabinet was locked and inaccessible to Residents and included the First Aid Kit. There were no visible immediate hazards or discrepancies observed.. BEDROOMS: There are six (6) Bedrooms, all of which are designated for Resident use. The bedrooms are furnished for single occupancy. There was appropriate furniture, bedding and linens. There were no visible hazards or discrepancies observed.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COLONY - VALLEY GLEN 4, THE	FACILITY NUMBER: 195850101
	VISIT DATE: 11/10/2020

NARRATIVE

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BATHROOMS: There are four (4) full Bathrooms. The bathrooms are located inside Bedrooms #1, 5 and 6 and between Bedrooms #3 & 4. The Bathrooms located inside of Bedrooms #1, 5 & 6 are designated for the use of the assigned occupants of those bedrooms only. The remaining Bathroom is designated for the use of the remaining Residents and Staff. All bathrooms are equipped with appropriate grab bars and supplied with appropriate paper and hygiene products. There were no visible hazards or discrepancies.

COMMON AREAS: These include the 2 Living Rooms, a TV Room, a Breakfast area and a main Dining Room. The common areas were furnished to accommodate a maximum capacity of six (6) residents. All required postings were located inside the main entrance. There was a hand sanitizing station inside the main entry. Required COVID-19 postings were located at the main entrance both interior and exterior and throughout the facility. There were no visible hazards or discrepancies.

OFFICE & STAFF AREAS: There is a Staff break room adjacent to the kitchen. There is a small Office area located in the Breakfast area. The main Office area is accessible through the refurbished garage and backyard and is inaccessible to Residents.

LAUNDRY: The laundry facilities are located in the refurbished garage and accessible from the exterior only. Laundry supplies are kept inaccessible to Residents.

SURROUNDING GROUNDS: The Front Yard has a driveway, paved walk ways and landscaped areas. The Back Yard is fenced and gated and includes paved walking paths, patios, landscaped areas, furniture appropriate for outdoor use and shade. The Facility has handicapped ramps. There were no visible immediate hazards or deficiencies.

The following will be required before a license may be issued:

FACILITY SKETCH - FLOOR PLAN (LIC 999): Revise and label bathrooms, kitchen and emergency water, electricity & gas shut-off.
FACILITY SKETCH - YARD (LIC 999): Submit a yard sketch.

A copy of the Licensing Report was provided via email for signature and return.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Eva Miller	TELEPHONE: (818) 326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 11/10/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/10/2020

LIC809 (FAS) - (06/04)

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