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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600961
Report Date: 10/20/2023
Date Signed: 10/23/2023 04:32:04 PM


Document Has Been Signed on 10/23/2023 04:32 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:NORTHRIDGE RETIREMENT VILLAFACILITY NUMBER:
197600961
ADMINISTRATOR:STEPHANIE FLORESFACILITY TYPE:
740
ADDRESS:18907 LIGGETT STREETTELEPHONE:
(818) 203-9411
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 5DATE:
10/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lani Manzano- LicenseeTIME COMPLETED:
04:15 PM
NARRATIVE
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On 10/20/23 Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by staff and explained the reason for the visit. Shortly after, LPA met with Licensee Lani Manzano. A tour of the physical plant was conducted at 10:30AM.Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were stored in locked drawers and cabinets. Medications are locked in the kitchen cabinet. Medications observed to be locked and inaccessible to clients. LPA observed fully stocked first aid kit in the kitchen drawer. Laundry Area: located through the kitchen. Appliances observed to be in good repair. Laundry detergents were locked inaccessible to residents. Temperature: Facility maintains a comfortable temperature of 78 degrees Fahrenheit.Surrounding Grounds: Entry/exits were observed to be locked. The outdoor area was clean and free of hazards. There is large deck with a patio table and chairs shaded for residents use in the backyard. Patio furniture observed to be in good repair with adequate seating for the residents.Smoke Alarms and Carbon Monoxide: observed to be functional and The fire extinguisher is located in the laundry room observed to be fully charged. Bathrooms: There were three (3) bathrooms in the facility. One (1) bathroom in hallway which is the main, one (1) in a private room and (1) in the laundry room designated for staff use. All bathrooms were clean, properly supplied and had functional fixtures. Water temperatures were: 114.2 and 118.4 degrees Fahrenheit. Bedrooms: There were five (5) bedrooms in the facility. Four (4) designated for residents' use and one (1) for staff use. All bedrooms were clean, properly furnished and had sufficient lighting. Common Areas: This includes the living room dining areas were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. LPA reviewed files for all residents. During file review LPA observed 2 missed medication dose for Resident#1 (R1) on 09/29/23. Licensee stated that R1 refused to take medication on that day. Licensee failed to notify CCLD regarding about the incident.

(Continue on 809C)

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


Document Has Been Signed on 10/23/2023 04:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364


FACILITY NAME: NORTHRIDGE RETIREMENT VILLA
FACILITY NUMBER: 197600961

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)


This requirement is not met as evidenced by: The licensee shall assist residents with self-administered medications as needed.
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above. R1 missed mediication dose for FAMOTIDINE 20MG on 09/29/23 and AMLODIPNE BESYLATE 5MG on 09/29/2023. R1 did not receive meds according to physician orders. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/23/2023
Plan of Correction
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Licensee agreed to submit a written plan for staff to follow when residents miss a dose of medication for any reason. The plan should include immediate contact with the resident physician and CCLD. Plan to be submitted by POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORTHRIDGE RETIREMENT VILLA
FACILITY NUMBER: 197600961
VISIT DATE: 10/20/2023
NARRATIVE
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 LPA reviewed files for staff regularly scheduled at the facility. Staff files included current first aid and CPR certifications as well as sufficient training documentation.

Exit interview conducted. Deficiencies cited, appeal of rights and a copy of this report given.

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3