195850205-2-1-2024-29-AS-SURA-D22UTA-20240201145134

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850205
Report Date: 01/24/2024
Date Signed: 02/01/2024 02:51:54 PM

Document Has Been Signed on 02/01/2024 02:51 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 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: 4	DATE:	01/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Paige Porter		TIME COMPLETED:	04:30 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required
annual inspection at 1:45 p.m. LPA Urena met with Paige Porter, Program Director (PD), and explained the reason for the visit.

The LPA, and the PD 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: Appliances in the kitchen were clean, and all appeared functional. Kitchen, laundry, and house cleaning supplies are stored, locked, and located in the laundry room and supply room. 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.
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.
BATHROOMS: The bathrooms are fully stocked with paper towels, hand soap, and hand washing signs. The showers have non-skid mats. Weekly water temperature logs indicate the water temperature is within approved temperatures.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The four (4) fire extinguishers were fully charged and were last serviced on different dates: 02/15/2023 and 04/14/2023. The LPA observed required postings throughout the common space. A fireplace was observed in the common area on the first floor and the common area on the second floor. Both fireplaces had a fireplace cover. Continues on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONTARE VISTA	FACILITY NUMBER: 195850205
	VISIT DATE: 01/24/2024

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

RECORDS: Records review began at 3:29 p.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 4:00 p.m.; medications are centrally stored and locked in a locked cabinet in the medication room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/24/2024

LIC809 (FAS) - (06/04)

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