197601221-5-3-2022-31-AS-MCAA-CE3T74-20220503142806

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197601221
Report Date: 05/03/2022
Date Signed: 05/03/2022 02:28:38 PM

Document Has Been Signed on 05/03/2022 02:28 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:	MARBLE TERRACE		FACILITY NUMBER:	197601221
ADMINISTRATOR:	GODLEWSKA, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	5811 DONNA AVE.		TELEPHONE:	(818) 708-2327
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 5	DATE:	05/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Bozena "Bonnie" Kozbial		TIME COMPLETED:	02:30 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) Michael Cava conducted an annual infection control inspection. LPA met with the administrator, Bozena "Bonnie" Kozbial and advised her of the visit. The current census is five (5). Facility license and sketch, rights of resident council, grievance/complaint procedures, emergency disaster plan, resident bill of rights, personal rights, and neighborhood complaint procedures visibly posted. Annual fees are current and administrator certificate expires 7/31/2022 which is current and valid. Bonnie stated she is in the process of renewing her certificate.

A physical plant tour of the facility inside and outside was conducted with the Administrator. The following common areas: living, dining, kitchen, resident bedrooms, bathrooms, staff room and office, were inspected to ensure the facility was in compliance with Title 22 Regulations:

Kitchen/Food Supply: Food service area had Licensing requirement of (7) day nonperishable, and (2) day perishable. Food was properly stored in a healthy manner. Snacks and beverages are available for clients. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas were clean and inaccessible to pests. Appliances were functional and clean. Chemicals, household supplies, and knives, and medication was locked and secured.

Living/dining/family/staff area and office: All indoor passageways were free from obstruction; inside temperature was comfortable and set at 72 degrees, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort.

Bedrooms: The facility has (4) bedrooms; (2) are private and (2) are shared. All bedrooms were properly furnished and supplied with appropriate bedding and linens. Rooms observed to have bedspread, sheets, pillowcase, mattress pad, and blankets, which were all in good repair. There were sufficient linens observed and available.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

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 2

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: 05/03/2022

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
26
27
28
29
30
31
32

Bathrooms: There are (3); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured in resident’s bathroom at 113 degrees Fahrenheit.

Surrounding Grounds: Smoke alarms and carbon monoxide detectors were tested and operating properly. Fire extinguisher is fully charged. The charge date is 5/18/21. Administrator stated the fire department will be out by mid May to inspect the facility and their fire extinguisher. First aid kit furnished and fully equipped. All exit doors have alarms; all were operating. There were no visible hazards, and passageways were free from obstruction. There is a covered patio in the backyard with appropriate seating for residents when sitting outside. There are exercise equipment for the residents to utilize. The swimming pool is gated with a five foot fence and is locked and secured all around. The front yard/driveway posed no immediate health and safety threat to the residents in care. There is fountain, but no water located at the front lawn.

Pursuant to title 22, division 6, chapter 8, there were no deficiencies observed during the day's inspection. The administrator was advised and a copy of this report given.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2