197600865-12-2-2023-31-AS-AALR-CY5TDK-20231202133827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197600865
Report Date: 12/02/2023
Date Signed: 12/02/2023 01:38:32 PM

Document Has Been Signed on 12/02/2023 01:38 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VAGTHOL'S RESIDENTIAL CARE CENTER		FACILITY NUMBER:	197600865
ADMINISTRATOR:	CHAMU-NESTOR, FRANCISCA		FACILITY TYPE:	735
ADDRESS:	418 N. MARIPOSA		TELEPHONE:	(818) 562-1447
CITY:	BURBANK	STATE: CA	ZIP CODE:	91506
CAPACITY: 6		CENSUS: 6	DATE:	12/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	07:15 AM
MET WITH:			TIME COMPLETED:	01:45 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) Antonia Alvizar conducted an unannounced Annual Required visit to this facility. LPA met with staff (S1), Veronica Inofinada and granted entry. S1 called via phone Interim Administrator, Rodel Serrano. At approximately 8:13a.m. Mr. Serrano joined us and explained the reason for the visit. At 8:00a.m. S1 and LPA tour of the physical plant for compliance with safety, maintenance, and operational requirements. LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following: Vagthol's Residential Care Center an adult residential facility licensed to serve six (6) non-ambulatory, developmentally disabled adults between the ages of 18 to 59. Facility is a single-story house in a residential neighborhood and consisting of a kitchen, four (4) bedrooms, two (2) full bathroom, common areas, currently occupying six (6) residents. There is one entrance being utilized at the facility, there are required posters at the main door. Smoke detectors are hard wired and are interconnected. Smoke detectors and Carbon Monoxide detectors were tested and function properly. Facility disaster drill was conducted on 11/23/2023. The facility maintains a comfortable temperature at 74°F. There were charged fire extinguishers in the facility. Fire extinguishers are located in the end of hallway, kitchen, and garage. Fire extinguisher is fully charged and services on 09/05/2023. Cleaning supplies and toxic substances are inaccessible to residents. Hot water temperature was tested in bathrooms and in the kitchen. The hot water temperatures measured between 109.7 - 111.6 degrees Fahrenheit (F) which are within the required range for residents comfort and safety.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VAGTHOL'S RESIDENTIAL CARE CENTER	FACILITY NUMBER: 197600865
	VISIT DATE: 12/02/2023

NARRATIVE

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Continued from 809)
Kitchen: The kitchen appeared clean and fixtures functional. Kitchen knives and other sharp items are stored in a lock cabinet underneath the kitchen sink. The supply of dishes and eating utensils was more than adequate. Household cleaning and supplies are kept locked in a hallway closet, garage, and cabinet under the sink.
Bedrooms: The residents’ bedrooms were properly furnished and had adequate lighting and closet space. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. There was extra bedding and linens such as sheets, pillowcases, mattress pads, and blankets in the hallway closet.

Bathrooms: LPA observed all bathrooms to be clean, properly supplied and had functional fixtures. LPA observed grab bars in both bathrooms. The bathrooms had non-skid mat in shower. Residents have enough personal hygiene supplies. There was extra personal hygiene supplies in the hallway closet and garage.

Common Areas: The living room has a couch, a massage and recliner chair. S1 indicated that resident had just finished having breakfast. The dining area has table with 6 chairs, two (2) credenzas, a television, and a functional telephone. At 7:15a.m. LPA observed residents was watching television. At 10:00a.m. LPA observed residents having coloring in the dining table.
Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use in the back of the facility. There are no bodies of water and firearms on the premises.
Garage: Detached located in the rear of the facility, which stores personal protected equipment (PPE), emergency food, maintenance supplies, one (1) operation refrigerator with extra perishable food. Non-perishable food are stored in a cabinet.
Laundry Room located in the garage: Equipped with washer and dryer. Laundry supplies are kept locked in a cabinet.

In addition to the physical plant LPA conducted a file review for all residents and staff regularly scheduled. Staff have current first aid and training documentation showing training completed. Resident records observed to be complete at this time.

Per California Code of Regulations (CCR), Title 22, Division 6, Chapter 8, deficiencies were not observed/cited. Exit interview conducted and copy of report provided to Mr. Serrano

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
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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