195850136-2-22-2021-29-AS-ARIN-BYGVVH-20210222154623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850136
Report Date: 02/22/2021
Date Signed: 02/22/2021 03:47:58 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:	FALLBROOK ESTATES		FACILITY NUMBER:	195850136
ADMINISTRATOR:	LACSON, DAVID		FACILITY TYPE:	740
ADDRESS:	5515 FALLBROOK AVENUE		TELEPHONE:	(818) 712-0904
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 0	DATE:	02/22/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	David Lacson		TIME COMPLETED:	02:45 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) Aja Richardson conducted a Prelicensed visit at 1:30 pm and met with the Administrator David Lacson. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually via Facetime. This application is for a Residential Care Facility for the Elderly (RCFE) with a capacity of 6. Approved for 1 bedridden resident. The administrator is applying for a hospice. At 1:30 pm, a tour of the physical plant was conducted. During the visit LPA observed the following: KITCHEN: The facility is equipped with a spacious kitchen that is supplied with adequate dining and cook ware. Appliances and fixtures are clean and functional. The kitchen trash can was equipped with a lid. BEDROOMS: There are (5) bedrooms for residents in care. Room 1 and 3 are private rooms and rooms 3 and 5 are shared. Room 4 is a staff bedroom which is kept locked. All bedrooms were supplied with all required bedding and linens. There is sufficient lighting as well as closet and drawer space available. BATHROOMS: There are (3) full bathrooms. Bathrooms are equipped with toilet and shower grab bars. There is sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water delivered at 110.6, 107.6, 116.0.degrees F.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

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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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: FALLBROOK ESTATES	FACILITY NUMBER: 195850136
	VISIT DATE: 02/22/2021

NARRATIVE

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COMMON AREAS: These include a living space equipped with a television. There is a dedicated area for the posting of required documents during the front entry way. Smoke detectors checked and is connected to carbon monoxide. Staff records are stored in locked cabinet in living room. Medications and resident records are stored in locked storage unit.

LAUNDRY ROOM: There is a laundry area located in hallway with a washer and dryer. Detergents and cleaning supplies will be stored in locked cabinet in laundry area.

SURROUNDING GROUNDS: The property is equipped with fencing and gates . There is furniture appropriate for outdoor use including a covered patio providing shade.

Component III was completed during visit.

At this time facility has passed pre licensing inspection.

Exit Interview Conducted. Report emailed to Administrator and hard copy signature requested.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/22/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2021

LIC809 (FAS) - (06/04)

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