197603012-12-4-2024-31-AS-MAGN-DBMVUJ-20241204154448

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603012
Report Date: 12/04/2024
Date Signed: 12/04/2024 03:45:42 PM

Document Has Been Signed on 12/04/2024 03:45 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 VILLA, LLC		FACILITY NUMBER:	197603012
ADMINISTRATOR/ DIRECTOR:	STEPHANIE FLORES		FACILITY TYPE:	740
ADDRESS:	18901 LIGGETT ST		TELEPHONE:	(818) 203-9411
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	12/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:15 AM
MET WITH:	Lani Manzano		TIME VISIT/ INSPECTION COMPLETED:	01:45 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) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff and explained the reason for the visit. Administrator Lani Manzano was contacted and arrived shortly after. At approximately 10:25 am, with the assistance of the Administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The first Aid kit was observed to be fully stocked. Laundry Area: The laundry area is located through the kitchen. Appliances were observed to be in good repair. Laundry detergents were locked in a cabinet. LPA observed a fire extinguisher with a purchase date of 09/03/24. Smoke alarms were observed and tested to be functional. Bedrooms: There were four(4) bedrooms designated for residents' use and one (1) room is designated for staff. All four bedrooms used by residents were properly furnished with appropriate bedding and linens with sufficient lighting. Bathrooms: There were three (3) bathrooms in the facility. One (1) bathroom is the main bathroom and is located in the hallway. One (1) is in a private resident room and one (1) is designated for staff located in the laundry room. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 108.9 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. The dining room table is large enough to sit the capacity of the facility. Seating such as couches were in good repair and sat the capacity of the facility. The fireplace located in the living room is closed, non-operational, and blocked off. Surrounding Grounds: Entry/exits were free of obstruction. (Continue on 809C)

Eva Miller	TELEPHONE: (818) 596-4373
Mariana Agban	TELEPHONE: 818-738-4525
	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: NORTHRIDGE RETIREMENT VILLA, LLC	FACILITY NUMBER: 197603012
	VISIT DATE: 12/04/2024

NARRATIVE

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There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliant with licensing forms. Medications: Medication and Medication Records were review for proper documentation.

Temperature: Facility maintains a comfortable temperature of 77 degrees Fahrenheit.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC809 (FAS) - (06/04)

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