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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602257
Report Date: 02/24/2022
Date Signed: 02/25/2022 08:26:59 AM

Document Has Been Signed on 02/25/2022 08:26 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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MARBLE TERRACE IIFACILITY NUMBER:
197602257
ADMINISTRATOR:GODLEWSKA, ELIZABETHFACILITY TYPE:
740
ADDRESS:19030 MIRANDA AVENUETELEPHONE:
(818) 345-8971
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 6DATE:
02/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:30 AM
MET WITH:Elizabeth GodlewskaTIME COMPLETED:
12:00 PM
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A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analysts (LPAs) Gary Tan and Michael Cava. LPAs met with the administrator, Elizabeth Godlewska and stated the purpose of the visit. LPAs observed that all six (6) residents were at the facility during the visit.

The tour of the physical plant was conducted at 8:30am and the following were noted:

The main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear a mask and must be screened. The screening area is located near the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPAs were screened by staff upon entry. All staff were observed to be wearing a mask.

The facility submitted an approved Mitigation Plan.

Signs to wear a mask and other COVID 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with covers.

The facility has a designated visitor's area at the front and backyard. The facility has a sufficient supply of PPE in the storage room.

Resident rooms: LPAs toured 5 resident rooms. All 5 out of 5 rooms meet regulation. LPA observed rooms to have appropriate bedding sheets, pillowcase, mattress pad, and blanket which are in good condition. There is at least one chair, night stand and sufficient lighting for each client. The mattresses and bedsprings were also checked for condition.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2022
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MARBLE TERRACE II
FACILITY NUMBER: 197602257
VISIT DATE: 02/24/2022
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Bathrooms: LPAs toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured between 110 to 120 degrees F. LPA observed appropriate grab bars and non-skid mat in each bathroom. Towels and washcloths are not shared. Residents have sufficient amounts of supplies for personal hygiene items which is provided by the Licensee.

Common Areas: LPAs toured all common areas of the facility. LPAs observed common areas to be clean and furniture in good repair. The facility maintains a comfortable temperature at 75 degrees F. LPAs observed fire extinguishers throughout the facility to be full and serviced. Last service date was 5/18/2021. The smoke/carbon monoxide detectors are operational. There are no issues with Fire Clearance.

Outside areas: LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. There are no bodies of water which is unsecured.

The garage is attached to the home and is kept locked inaccessible to clients. It is being used as storage.

Food Inspection: LPAs conducted a food inspection tour. LPAs observed there to be sufficient stock of two- perishable and seven-day non-perishables foods. Snacks and beverages are available for clients in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. LPAs observed the door to the kitchen which is an exit to the side of the facility. Cleaning supplies, pesticides or toxins were stored and locked away.

Laundry: There is enough linen available to change weekly or more if need.

Pursuant to CA code of Regulations Title 22 or Health and Safety Code. No deficiencies observed during the day's visit. Exit interview conducted and a copy of this report provided.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2022
LIC809 (FAS) - (06/04)
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