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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850341
Report Date: 06/10/2024
Date Signed: 06/10/2024 02:21:03 PM

Document Has Been Signed on 06/10/2024 02:21 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:APEX ADULT CAREFACILITY NUMBER:
195850341
ADMINISTRATOR/
DIRECTOR:		SIAS, ALEXISFACILITY TYPE:
735
ADDRESS:6726 1/2 GAVIOTATELEPHONE:
(818) 378-7422
CITY:LAKE BALBOASTATE: CAZIP CODE:
91406
CAPACITY: 4CENSUS: 0DATE:
06/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:15 AM
MET WITH:Justin Levi and Alexis SiasTIME VISIT/
INSPECTION COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Valeria Conway conducted an announced Pre-Licensing Inspection to the above listed facility. Upon arrival LPA met with Licensee Representative Justin Levi and Administrator Alexis Sias. Entrance interview conducted.

An application to operate an Adult Residential Facility (ARF) was received by Community Care Licensing (CCL) on 01/23/2023. A Fire Clearance was approved for a maximum capacity of four (4) non-ambulatory clients on 10/17/2023. The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Lake Balboa, CA. This facility will be housing clients from Regional Center, and it will be classified as a Level 4I housing. Regional Center application is in process and not approved at the time of the visit. This facility doesn’t have a staff room, facility will provide 24/7 care.

At 10:25 am a tour of the physical plant was conducted and the following observed:

BEDROOMS: There are four (4) bedrooms, all of which are designated for client use. All bedrooms are for single occupancy. All bedrooms were equipped and supplied with appropriate furniture, bedding, and linens. No client bedroom will be used as a public or general passageway to another room, bath, or toilet. There were no visible hazards or discrepancies observed. Auditorial signal was observed in each door around the facility.

Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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 3
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: APEX ADULT CARE
FACILITY NUMBER: 195850341
VISIT DATE: 06/10/2024
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Continued from LIC-809

BATHROOMS: There are two (2) bathrooms, LPA observed toilet paper and soap ready to use, paper towels and other hygiene products will be provided before facility admits clients. Additionally, bathrooms had nonslip rugs, and grab bars. Water temperatures were measured in all client bathrooms and measured within the required range of 105 degrees F to 120 degrees F at the time of the visit.

KITCHEN: Appliances and fixtures appeared clean and functional. At the time of the visit, LPA did not observe any non-perishable nor perishable food because there are no client residing in the facility at the moment. Applicant representative stated that before admission of a client, facility will have enough perishable and non-perishable food to accommodate a maximum capacity of four (4) clients and facility staff for seven (7) days. There was sufficient dining and cookware to accommodate a maximum capacity of four (4) Clients. Knives and other sharps will be stored in locked under-sink cabinets. There were no visible immediate hazards observed. LPA observed an empty medicine cabinet next to the kitchen counter, 1st aid kit was observed on top of medicine cabinet.

COMMON AREAS: These include the Family Room and Dining Room. Additionally, a detached laundry room was observed by LPA. The staff will assist clients with all laundry needs. Cleaning supplies and detergents will be locked and inaccessible to clients. Night lights were observed in hallways passages to nonprivate bathrooms and in the bedrooms. The common areas were furnished to accommodate a maximum capacity of four (4) clients. A fire extinguisher was observed throughout the facility; it was fully charged and last serviced 04/24/2024. At 10:34AM, hardwired combination carbon monoxide/smoke detectors were tested and were functional at the time of the visit. Phone and internet system will be connected before the first client is admitted. Facility is clean, safe, sanitary and in good repair at the time of the visit. LPA observed sufficient amount of emergency water and food in a closet in the family room. Surveillance cameras are in place however they are not working at the time of the visit.

Continued on LIC-809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
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: APEX ADULT CARE
FACILITY NUMBER: 195850341
VISIT DATE: 06/10/2024
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Continued from LI-809C

SURROUNDING GROUNDS: Facility is providing a shaded, comfortable, and furnished outdoor activity area for clients. LPA observed a plant holder/pot with water inside and some grass clippings, weed, sticks, plants leaves and dirt in the backyard. Applicant representative stated that gardeners will come this week and get rid of the pot and clean all surfaces. All outdoor and indoor passageways were observed free of obstruction.

COMPONENT III ORIENTATION: A Component III Orientation was conducted with Licensee Representative Justin Levi and Administrator Alexis Sias during today's visit.

The following needs to be completed/Photos sent to LPAs prior to licensure:

 Clear backyard of all debris and provide proof.
 Fix auditory signal wire on bedroom # 2 and add an auditory alarm in bedroom #1.

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 conducted. A copy of the Licensing Report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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