195850103-11-4-2020-29-AS-EMIR-BV2VC3-20201104151828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850103
Report Date: 11/04/2020
Date Signed: 11/04/2020 03:18:34 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 - SHERMAN OAKS 2, THE		FACILITY NUMBER:	195850103
ADMINISTRATOR:	MARASIGAN, CLAUDETT		FACILITY TYPE:	740
ADDRESS:	5420 TYRONE AVENUE		TELEPHONE:	(818) 652-9121
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91401
CAPACITY:	6	CENSUS: 5	DATE:	11/04/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Claudett Marasigan		TIME COMPLETED:	02:30 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 Claudett Marasigan. 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 07/17/20. The facility is currently operating as CARMEL - 2 - 197604971 and licensed to "Carmel Residential Care Inc.". The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Sherman Oaks, CA. A tour of the physical plant was conducted and the following observed: KITCHEN: Applicances 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 110F. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 Residents. The medications and First Aid Kit are located in a cabinet between the Kitchen and Bedroom #7 and are kept inaccessible to Residents. There were no visible immediate hazards or discrepancies observed.. BEDROOMS: There are seven (7) Bedrooms, six (6) of which are designated for Resident use and one (1) for Staff use. The Resident 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: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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 - SHERMAN OAKS 2, THE	FACILITY NUMBER: 195850103
	VISIT DATE: 11/04/2020

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
26
27
28
29
30
31
32

BATHROOMS: There are five (5) Bathrooms (2 Full Bath and 3 Half Bath). The full bathrooms are located outside of the bedrooms and are designated for both Resident and Staff use. The half bathrooms are located inside Bedrooms #1, 5 and 6 and are designated for the use of the assigned occupants of those
bedrooms. 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 Living Room and 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: Bedroom #7 is designated for staff use only and is kept inaccessible to Residents. The garage has been refurbished for use as an Office. Facility Files and Records are located in the Office and are inaccessible to Residents and visitors.

LAUNDRY: The laundry facilities are located between the kitchen and Bedroom #7. Laundry supplies are kept in a locked cupboard and are inaccessible to residents.

SURROUNDING GROUNDS: The property is fenced and gated. The front yard includes lawn areas and a paved driveway. The backyard includes lawn and landscaped areas and a covered patio. There is furniture appropriate for outdoor use and shade as well as a wheelchair accessible ramp.

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: 11/04/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2020

LIC809 (FAS) - (06/04)

Page: 2 of 2