195850205-1-24-2022-29-AS-SURA-CAYKXG-20220124071727

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850205
Report Date: 01/21/2022
Date Signed: 01/24/2022 07:18:05 AM

Document Has Been Signed on 01/24/2022 07:18 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MONTARE VISTA		FACILITY NUMBER:	195850205
ADMINISTRATOR:	MODRESKY, MICHEAL		FACILITY TYPE:	772
ADDRESS:	14339 VALLEY VISTA BLVD		TELEPHONE:	(917) 374-4215
CITY:	SHERMAN OAKS	STATE: CA	ZIP CODE:	91423
CAPACITY: 6		CENSUS: 0	DATE:	01/21/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Elliott Liebhard		TIME COMPLETED:	04:00 PM

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The pre-licensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived at the facility at 1:00 p.m., and met with applicant Elliott Liebhard, and facilities director Katarina Boshoff. This is a new facility application for six ambulatory residents.

The LPA, the applicant, and the facilities director 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 knives are stored locked and inaccessible in the pantry room. A seven day supply of non- perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food. Kitchen, laundry, and house cleaning supplies are stored, locked, and located in the laundry room. Hot water temperature was recorded at 116 degrees Fahrenheit.

BEDROOMS: There are three bedrooms for resident use, double occupancy. Lighting in the rooms appeared adequate. All bedrooms had adequate closet and drawer space for clothing and personal belongings. Hot water was tested in residents’ bathrooms; it measured 116 degrees Fahrenheit.

BATHROOMS: The bathrooms are fully stocked with paper towels, hand soap, and hand washing signs. The showers have non-skid mats. Hot water temperature was recorded at 116 degrees Fahrenheit.

Continues on LIC809 C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022

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: MONTARE VISTA	FACILITY NUMBER: 195850205
	VISIT DATE: 01/21/2022

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COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment in the group rooms and outdoor area.

Resident and staff records will be stored in a filing cabinet in the filing room located on the second floor. Medications will be stored in locked cabinets in the medication room located on the first floor. The first aid supplies were complete, including a thermometer and a current version of a first aid manual.

The facility’s smoke/carbon monoxide alarm systems are hard wired. All rooms were tested, and all smoke/carbon monoxide alarm systems were in operating condition. There are three fire extinguishers throughout the facility. They are charged, and were maintained on 9/2021. The laundry area is located behind locked doors. The supply of extra bed and bath linens is adequate. There is a functioning telephone on the premises. Infection control and other posters are posted throughout the facility and hallways.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the outdoor, backyard area of the facility, and is furnished with outdoor furniture for residents’ use. The building has a central entrance for residents and visitors. Fire emergency gates are clear of obstructions. A fenced, and locked swimming pool is found in the back of the house.

Applicant completed Component III orientation at this time.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and reviewed with Montage Recovery CA LLC representative, Katarina Boshoff. A copy of the report was provided via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022

LIC809 (FAS) - (06/04)

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