197600348-12-2-2023-31-AS-GSAO-CY5SJK-20231202125517

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197600348
Report Date: 12/02/2023
Date Signed: 12/02/2023 12:55:24 PM

Document Has Been Signed on 12/02/2023 12:55 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 S.RO, 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: 3	DATE:	12/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Maria Fe Del Rosario		TIME COMPLETED:	01:15 PM

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At 925AM Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced One (1) Year, Annual visit for this facility. LPA was greeted by administrator and disclosed the purpose of this visit. The census, client and staff roster were obtained.

LPA conducted a tour of the physical plant at 10:30am escorted by the administrator.

There are hand sanitizing stations all over the facility including signs to wear a mask and other Covid 19 prevention protocol signs throughout the facility. The signs that were displayed were disaster plan, client/roster, licensee certificate, facility sketch, LGBT-(lesbian, gay, bisexual, and transgender), personal rights, house rules against the wall next to the kitchen area.

Resident bedrooms: There are three (3) client bedrooms. Bedroom two (2) is a single, housed room that has a private bathroom which is accessible and use for other clients. That private bathroom is also located next to room three (3). Bedroom three (3) is a single, housed room. Bedroom four (4) is a shared room. Bedroom one (1) is a shared, staff room. There is another bathroom in the house located next to the staff room which is also accessible to the clients for use. There is a cabinet in the hallway next to the staff bedroom with extra linen. The hot water temperature was measured for the two (2) bathrooms to ensure it is within the regulations. The water temperature range was between 117.5- and 117.1 degrees Fahrenheit. The bathrooms had proper signs displaying proper hygiene. The bathrooms and restrooms had proper supplies of toilet paper, napkins, grab bars and toilet was functioning properly.

The living room was observed to have adequate seating for clients. Administrator confirmed there are four (4) ambulatory, female clients. The living area had furnishings and sufficient lighting. There is a fireplace that is not useable and has a covering inaccessible to the clients.

LIC 809-C continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JARAVATA TRIBUNE HOME	FACILITY NUMBER: 197600348
	VISIT DATE: 12/02/2023

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There is a dining room that the clients can seat and use. There is enough seating for four (4) clients. There is internet, a television and a phone line for use. There is enough furnishings and enough lighting.

The smoke alarms were present in each room and function properly. There is additional carbon monoxides attached to wall outlets throughout the house.

The Kitchen area LPA observed the refrigerator and the cabinets to have enough food storage and supply (perishable and nonperishable foods) for four (4) clients. The freezer is stocked with meats, poultry, and frozen vegetables. The sharps and cleaning supplies are kept locked and secured under kitchen sink. The client’s medications and first aid kit are locked and secured in separate cabinet next to the refrigerator in the kitchen. The first aid kit has sufficient supplies including a backup first aid kit. There are two fire extinguishers located in the kitchen area. There is a current, fully charged one with a receipt- 02/2023 and another back-up fully charged dated 03/2022. The kitchen area has a carbon monoxide attached to the wall outlet.

Temperature of facility wall thermostat is observed and set to 74 degrees Fahrenheit.

Garage/Backyard area The garage is attached to the house and can be entered from the staff room. There is a supply of extra canned foods, dried foods, extra paper towels, water supply, PPE’s, property from clients stored in separate bins. There is also a refrigerator located in the garage with extra food. There is also a washer and dryer located in the garage. In the backyard, a dining area situated under a covered patio has sufficient seating for the clients. There is table and chairs available for seating.

An exit interview was conducted, no citation issued, and a copy of this report was given to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/02/2023

LIC809 (FAS) - (06/04)

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