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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197603012
Report Date: 08/26/2022
Date Signed: 08/26/2022 01:17:20 PM


Document Has Been Signed on 08/26/2022 01:17 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:NORTHRIDGE RETIREMENT VILLA, LLCFACILITY NUMBER:
197603012
ADMINISTRATOR:LANI A. MANZANOFACILITY TYPE:
740
ADDRESS:18901 LIGGETT STTELEPHONE:
(818) 203-9411
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 5DATE:
08/26/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Lani ManzanoTIME COMPLETED:
01:30 PM
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On 8/26/22 at 12:30 p.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was allowed entrance by Administrator through the side door. LPA observed covid-19 signage, hand sanitizer and a visitor sign in log. Administrator screened LPA for infection control protocols.

LPA explained the purpose of the visit and an entrance interview was conducted.

LPA initiated a physical plant tour. This is a six (6) bedroom, three (3) bathroom Residential Care Facility for the Elderly. LPA was able to tour the home and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed in the laundry area and has a date of purchase of 9/2/2021. Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a comfortable temperature of 78 degrees Fahrenheit. LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms have adequate furnishings and are kept clean. Extra towels and linens were readily available. There is a covered shaded area in the back yard.

No deficiencies issued during today’s visit. Report was signed and delivered by Administrator and an exit interview was conducted.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 08/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/26/2022
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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