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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600348
Report Date: 09/12/2022
Date Signed: 09/12/2022 03:11:03 PM

Document Has Been Signed on 09/12/2022 03:11 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 HOMEFACILITY NUMBER:
197600348
ADMINISTRATOR:JARAVATA, MINAFACILITY TYPE:
735
ADDRESS:18416 TRIBUNETELEPHONE:
(818) 831-1332
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY: 4CENSUS: 4DATE:
09/12/2022
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
01:10 PM
MET WITH:Maria Fey Del RosarioTIME COMPLETED:
03:20 PM
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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced Case Management visit to this facility to determine if any health and safety issues exist as a result of Resident #1 (R1) and Resident #2 (R2) receiving bug bites. LPA met administrator at 1:10 pm and explained the reason for this visit.

A physical plant tour was conducted from 1:30 am to ensure no immediate health and safety risk safety hand facility is in compliance with Title 22 Regulations. LPA inspected R1 and R2 shared bedroom with administrator. R1 bedroom has two twin beds in room that are approximately 6ft apart. LPA observed both beds to include linens, mattresses, and pillows. Both beds, linens, mattresses, and pillows observed to be clean and free of any pests. LPA conducted an interview with the Administrator regarding the incident and the following was revealed: R1 and R2 both received first aid and linens washed in hot water and thoroughly dried. R1 and R2 bug bites cleared up a few days after first aid ointment applied. R1 was bitten again on 07/30/2022 and taken to urgent care. Per Administrator, doctor stated R1 was bitten by a spider and R1 issued a prescription during that visit. LPA observed and requested copy of medical visit report, doctor’s prescription, and relevant facility documents.

There were no health and safety risks present.

No Deficiencies cited. Exit interview conducted and report printed

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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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