197600348-4-14-2022-31-AS-TSMH-CDGSU5-20220414141035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197600348
Report Date: 04/14/2022
Date Signed: 04/14/2022 02:10:49 PM

Document Has Been Signed on 04/14/2022 02:10 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JARAVATA TRIBUNE HOME		FACILITY NUMBER:	197600348
ADMINISTRATOR:	JARAVATA, MINA		FACILITY TYPE:	735
ADDRESS:	18416 TRIBUNE		TELEPHONE:	(818) 831-1332
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91326
CAPACITY: 4		CENSUS: 4	DATE:	04/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Maria Fe Del Rosario Administrator		TIME COMPLETED:	02:10 PM

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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced One (1) Year Required Infection Control visit for this facility LPA was greeted by administrator who was observed wearing a mask LPA's temperature taken upon entry and Covid symptoms questions contained on sign in log for each visitor to complete. LPA disclosed the purpose of this visit.

LPA conducted a tour of the physical plant at 11:30 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

There are hand sanitizing stations all over the facility including signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors.

LPA was escorted to the livingroom and observed adequate seating for residents. Administrator confirmed there are four (4) ambulatory residents. The living area had furnishings and sufficient lighting. The area was clean and well kept.

Smoke alarms and carbon monoxide detectors were present and function properly. The three (3) fire extinguishers were current with receipts attached.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the four (4) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats, poultry, and frozen vegetables.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JARAVATA TRIBUNE HOME	FACILITY NUMBER: 197600348
	VISIT DATE: 04/14/2022

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The sharps and cleaning supply’s kept locked under kitchen sink. The resident’s medications and first aid kit are locked in separate hutch cabinet next to the refrigerator in the kitchen. LPA checked first aid kit and the first aid kit has sufficient supplies including a backup first aid kit.

Resident bedrooms: Three (3) resident bedrooms toured had the required furniture for residents’ comfort and safety. Common areas were observed for the ability to safely serve the needs of residents, including cleanliness, skid materials, locks, grab bars, and comfortable temperatures. LPA observed a sufficient supply of linens and PPEs in bathroom closet next to the living room.

There are two (2) bathrooms available for resident use. Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 117.5- and 118.8-degrees Fahrenheit. Hand washing, coughing etiquette, physical distancing, and other necessary signs were posted in common bathrooms, and in common areas of the facility.

There is a supply of canned foods, dried foods, extra paper towels, water and a six-month supply of PPE’s stored in the garage. Facility grounds were free of hazards. In the backyard, a dining area situated under a covered patio has sufficient seating for the residents. The table and four (4) chairs observed to be clean and functional.

No Deficiencies cited. Exit interview conducted and copy of report printed.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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