195850384-10-28-2024-29-AS-ABAN-DAGQKG-20241028121418

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850384
Report Date: 10/28/2024
Date Signed: 10/28/2024 12:15:03 PM

Document Has Been Signed on 10/28/2024 12:15 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 AT THE WOODLANDS		FACILITY NUMBER:	195850384
ADMINISTRATOR/ DIRECTOR:	BOSHOFF, KATARINA		FACILITY TYPE:	772
ADDRESS:	5316 LUBAO AVE		TELEPHONE:	(917) 374-4215
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY: 6		CENSUS: 5	DATE:	10/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Denise Ojarigi		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual inspection at 10:00AM. LPA was greeted by Program Manager (PM) Adam Guerrero and explained the reason for the visit. Chief Operating Officer (COO) Denise Ojarigi, Program Director (PD) Danielle Landis, and Regional Director of Nursing (RDN) Faridah Gonzalez arrived shortly during the visit.

Beginning at 10:03AM, the LPA and PM Guerrero 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. The following was observed:

OFFICE AREAS: LPA observed the office areas to be locked and inaccessible to clients. Medication room is kept locked.

LAUNDRY/GARAGE: LPA observed the locked and inaccessible laundry room. Detergents and chemicals were stored in locked cabinets. The garage is accessed from the laundry room and is kept locked. LPA observed an additional refrigerator/freezer, emergency food and water supply, and locked cleaning supplies in the garage.

COMMON SPACES: These include the office area, dining area, living room, group room, and game room. Common areas were appropriately furnished and in good condition. LPA observed the required postings at the entrance. LPA observed fire extinguishers to be fully charged and last serviced on 03/28/2024. There is a functioning telephone on the premises. Smoke and carbon monoxide detectors were tested at 12:05PM and were operable at the time of the visit.

Report continued on LIC-809C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

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 AT THE WOODLANDS	FACILITY NUMBER: 195850384
	VISIT DATE: 10/28/2024

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BEDROOMS: There are four (4) bedrooms in the facility; two (2) are designated for shared-client use and two (2) are designated for single-client use. There is no staff room in the facility as there is no live in staff. All client rooms were set up with beds, nightstands, lighting, chests of drawers, chairs and closet space.

BATHROOMS: There are five (5) bathrooms. The showers are equipped with nonskid surfaces and nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between 109.3 – 113.7 degrees Fahrenheit, which is within the required range.

KITCHEN: LPA toured the kitchen at 10:14AM. Knives and sharps are stored locked and inaccessible in a cabinet. The facility has a sufficient supply of perishable and non-perishable food. Appliances in the kitchen were clean and functional.

EXTERIOR: 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. 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. LPA observed a pool that was 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.

MEDICATIONS: Medications are stored inaccessible in the medication room. Beginning at 10:23AM, LPA observed medications for two (2) clients. Medications were observed to be properly documented on the centrally stored medications and destruction record and were in compliance with regulation, state, and federal law.

RECORD REVIEW: Records review began at 10:30AM. LPA observed all five (5) client records for documents including, but not limited to: needs and service appraisals, medical records, admissions agreement, and consent forms. LPA observed four (4) personnel records for documents including, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All client and personnel files were in order and had no missing documents.

Report continued on LIC-809C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

LIC809 (FAS) - (06/04)

Page: 3 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: MONTARE AT THE WOODLANDS	FACILITY NUMBER: 195850384
	VISIT DATE: 10/28/2024

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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 10/10/2024.

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

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2024

LIC809 (FAS) - (06/04)

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