195850384-10-10-2023-29-AS-BBAI-CWGSK7-20231010135617

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850384
Report Date: 10/10/2023
Date Signed: 10/10/2023 01:57:07 PM

Document Has Been Signed on 10/10/2023 01:57 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MONTARE AT THE WOODLANDS		FACILITY NUMBER:	195850384
ADMINISTRATOR:	BOSHOFF, KATARINA		FACILITY TYPE:	772
ADDRESS:	5316 LUBAO AVE		TELEPHONE:	(917) 374-4215
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY: 6		CENSUS: 0	DATE:	10/10/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Katarina Boshoff		TIME COMPLETED:	02:00 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) Brian Balisi conducted a pre-licensing visit to the above noted facility. The LPA met with applicant Katarina Boshoff. This is a change of location application from Montare on Vista #19760127 located at 18016 Valley Vista Encino CA 91316 to Montare at the Woodlands located at 5316 Lubao Ave #195850384 . The current capacity is for six (6) clients, the facility doesn't have any clients at this time. The fire clearance was granted for six (6) ambulatory clients. The facility is two story. At approx. 10:30am, a physical plant tour was conducted inside and out. The facility has four (4) private resident bedrooms. Client room #1 has a direct exit to the outside. There are no fire sprinklers in the facility. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. In addition, no bedroom was used as a passageway to another room, bath or toilet. There is no staff room at the facility. For NOC , there will be awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. There are five (5) bathrooms total. The resident bathroom(s) have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested in all the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Resident and staff records are to be stored in a cabinet in the office located across bedroom #4. Medications are to be centrally stored in a locked cabinet in the office as well. The first aid supplies were complete , including a thermometer and a current version of a first aid manual. First aid was stored inaccessible in the office. Continued on 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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 AT THE WOODLANDS	FACILITY NUMBER: 195850384
	VISIT DATE: 10/10/2023

NARRATIVE

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Continued from 809

Kitchen knives are stored in a locked cabinet to the left of the microwave. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to non private bathrooms. There are three (3) fireplaces that are non-operable at this time. It is screened and there are no tools. There is a common space upstairs that is planned to be used as a library at this time.

The facility has emergency exit signs . The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The facility smoke alarm system are battery operated. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. Fire extinguishers were observed fully charged and last serviced in Feb 2023.

The laundry room is located next to bedroom #4. Cleaning supplies and toxins were observed stored here and the room will be inaccessible to residents in care. The garage is located attached to the home. Emergency food supplies, extra non-perishable food, storage for clients, and facility equipment, tools and décor are to be stored here for future use.

Continued on 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

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 AT THE WOODLANDS	FACILITY NUMBER: 195850384
	VISIT DATE: 10/10/2023

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Continued from 809-C

The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are to be stored inaccessible to residents in care. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted at the entrance and outside of every room. The emergency telephone numbers are posted on the bulletin board at the entry way. Other required postings are posted on the white board as well.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the rear of the home. LPA observed appropriate furniture for outdoor use. There is one storage shed used to store building supplies at this time. The entire property is fenced. The gate to the front courtyard has a gate with a self-latching mechanism for persons to enter the front courtyard. There is a basketball court located in the front of the home. There is a pool located to the left of the home. LPA observed it to be inaccessible to clients, by a locked entry gate in the courtyard, a locked entryway in the game room, and a screened fence in the backyard. When the pool is in use there will be sufficient staff to observe clients in care.

Component III was conducted in conjunction with the visit.

The physical plant was not consistent with the submitted facility sketch/floor plan as the sketch notated a room as Office #2 , but it should have been notated as bedroom #4. Applicant updated facility sketch LIC 999 and also included a room marked "game room" on the sketch. An updated LIC 999 was provided to the Department.

No corrections required on a pre-licensing visit at this time. Exit interview conducted. Report issued and provided to Licensee.

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.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 10/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023

LIC809 (FAS) - (06/04)

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