197601800-5-4-2022-29-AS-SURA-CE4LGX-20220504084524

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197601800
Report Date: 05/03/2022
Date Signed: 05/04/2022 08:46:16 AM

Document Has Been Signed on 05/04/2022 08:46 AM - 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MEDAL RESIDENTIAL BOARDING & CARE		FACILITY NUMBER:	197601800
ADMINISTRATOR:	BELLA MEDALLA		FACILITY TYPE:	740
ADDRESS:	12952 ELKWOOD STREET		TELEPHONE:	(818) 503-3980
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 0	DATE:	05/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Bella Medalla		TIME COMPLETED:	12:30 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) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 11:00 a.m. This annual visit had an emphasis on infection control practices and procedures. The LPA spoke with administrator Bella Medalla, and explained the reason for the visit. The administrator communicated that currently they do not have residents, and do not know when they will have residents. The facility has not had residents for a year. The LPA advised the administrator to inform the LPA when they admit a new resident. The LPA and the administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The residents’ bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms are clean, sanitary and in operating condition. The common bathrooms were observed with appropriate signs and stocked with paper towels. Hand washing signs were posted in the common and private bathrooms.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
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)

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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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MEDAL RESIDENTIAL BOARDING & CARE	FACILITY NUMBER: 197601800
	VISIT DATE: 05/03/2022

NARRATIVE

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COMMON SPACES: At the time of the visit, furniture, walls, and flooring were observed to be in good condition. The LPA observed the required postings in the hallway. The LPA observed sanitizer interspersed throughout the facility.

BACKYARD: The backyard has a patio area with sitting furniture and umbrella for residents and family members to meet. There were no bodies of water observed.

INFECTION CONTROL: During today’s visit, the LPA spoke with staff and the Licensee Representative
regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station.

No deficiencies cited at this time. Exit interview conducted. Signatures obtained. The report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
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)

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