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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850101
Report Date: 12/10/2021
Date Signed: 12/10/2021 01:37:37 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, THEFACILITY NUMBER:
195850101
ADMINISTRATOR:LAU, MARISSAFACILITY TYPE:
740
ADDRESS:6245 MATILIJA AVENUETELEPHONE:
(818) 605-3984
CITY:VALLEY GLENSTATE: CAZIP CODE:
91401
CAPACITY:6CENSUS: 4DATE:
12/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Eleanor JimenezTIME COMPLETED:
11:45 AM
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On 12/10/2021, Licensing Program Analyst (LPA) Sandra Urena arrived at 9:45 a.m at the facility unannounced to conduct a required annual visit . This annual inspection had an emphasis on infection control practices and procedures. The LPA spoke with Licensee Representative Eleanor Jimenez and explained the reason for the visit.

At 10:15 a.m., the LPA and Eleanor Jimenez toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The residents’ bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms are clean, sanitary and in operating condition. The common bathrooms were observed with appropriate signs and stocked with paper towels. Hand washing signs were posted in the common and private bathrooms.

COMMON SPACES: The LPA and Ms. Jimenez observed the living room, dining room. At the time of the visit, furniture, walls, and flooring were observed to be in good condition. The LPA observed the required postings in the hallway. The LPA observed sanitizer interspersed throughout the facility. The backyard has a patio area with sitting furniture for residents and family members to meet. Record Review: The LPA reviewed staff and resident files and found the files to be in order.

INFECTION CONTROL: During today’s visit, the LPA spoke with staff and the Licensee Representative regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station.

No deficiencies cited at this time. Exit interview conducted with Licensee Representative Eleanor Jimenez. Signatures obtained. Report was issued via email.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 12/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2021
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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