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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197601221
Report Date: 05/25/2021
Date Signed: 05/25/2021 04:13:27 PM

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:MARBLE TERRACEFACILITY NUMBER:
197601221
ADMINISTRATOR:GODLEWSKA, ELIZABETHFACILITY TYPE:
740
ADDRESS:5811 DONNA AVE.TELEPHONE:
(818) 708-2327
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY:6CENSUS: 5DATE:
05/25/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Bozena KozbialTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility 11am to conduct an unannounced infection control inspection/visit. Upon arriving, LPA contacted the facility, and spoke to Co-Administrator Bozena Kozbial, who gave LPA current information pertaining to the residents and facility. The Co-Administrator reported to LPA, that there have not been any active or past COVID cases at the facility, and staff and residents have been vaccinated. The current census is (5). LPA was greeted at the front door by the Co-Administrator Bozena, who allowed LPA to enter; LPA’s temperature was immediately taken and documented; a list of COVID-19 questions was asked; and LPA signed in the visitor book. LPA observed all staff to have full mask covering; a hand sanitizing station; PPE supplies in drawer; and COVID-19, CDC, Department of Public Health, and Licensing postings on the walls throughout the facility. The Administrator Elizabeth Godlewska arrived shortly after, with food supplies for the facility.

The infection control inspection began with the Co-Administrator escorting LPA throughout the facility. The facility has (3) bedrooms; with (1) shared room and beds were kept (6) feet apart. All bedrooms were properly furnished; with each resident’s door posted with COVID-19 procedures and protocols. The common areas were observed to be clean, including bathrooms, with soap and towels. LPA conducted a mitigation plan review with the Co-Administrator, to obtain information on how the facility has implemented the plan. The Co-Administrator reported to LPA, the facility has hired an outside agency to continue with the COVID-19 surveillance testing, which is done every (2) weeks for staff and residents. The facility keeps documentation of the test results and other pertinent information pertaining to COVID-19. All new employee hires and new resident admits, must be properly screened and provided a negative COVID test, prior to entering the facility. Administration has conducted training to staff in relation to COVID-19 and has documentation, as well as staff have been notified that there is a paid sick leave policy in place. There are designated rooms for potential positive COVID residents. PPE, chemicals, cleaning supplies, emergency food and water, personal hygiene supplies, and paper products are stored in the garage area, which was locked and secured. LPA observed a (30) day supply of all items during the visit. LPA observed the facility has Licensing requirement for food

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
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: MARBLE TERRACE
FACILITY NUMBER: 197601221
VISIT DATE: 05/25/2021
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supply. Currently, the facility has sufficient staff, and has a hiring plan in place if needed. The facility has not had any positive COVID-19 reports for staff or residents. The Co-Administrator informed LPA that they continue to implement the best practices for their facility; which has kept them COVID-19 free. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted with Administrator and Co-Administrator. In order to continue implementing safe measures surrounding the situation of the Coronavirus Disease 2019 (COVID-19), today’s Licensing report (LIC809) would not be issued during the visit; but submitted via email by the end of the day, and signature will be provided by both LPA and Administrators.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 05/25/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2021
LIC809 (FAS) - (06/04)
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