197603823-7-29-2021-31-AS-RVAA-C5DRYU-20210729132654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603823
Report Date: 07/29/2021
Date Signed: 07/29/2021 01:27:03 PM

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:	NORTH LAKE VILLAS INC.		FACILITY NUMBER:	197603823
ADMINISTRATOR:	NOURIT BRAUN		FACILITY TYPE:	740
ADDRESS:	2851 N. LAKE AVE		TELEPHONE:	(626) 398-8668
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY:	30	CENSUS: 23	DATE:	07/29/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:08 AM
MET WITH:	Adam Braun, Director of Operations		TIME COMPLETED:	01:00 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) Rosaura Valenzuela conducted an unannounced Required One (1) year-Infection Control inspection to the facility. LPA met with Adam Braun, Director of Operations and explained the reason for the visit. A tour of the physical plant was conducted at 10:10am and the following was noted: There is only one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet and hand sanitizer is available. LPA was screened upon entry. The facility had submitted and approved Mitigation Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has sufficient stock of PPE in the storage room. The facility has fifteen (15) bedrooms and nine (9) bathrooms currently occupying twenty-three (23) residents. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

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: NORTH LAKE VILLAS INC.	FACILITY NUMBER: 197603823
	VISIT DATE: 07/29/2021

NARRATIVE

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Living and dining room furniture were checked. The living room is neat and clean. The facility maintains a comfortable temperature at 76 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguishers are located throughout the facility.

There is no body of water at the facility. Passageways were observed to be clear from obstruction.

Laundry area is located in the lower level. Laundry detergents, cleaning agents and other toxins are stored in a cabinet which was observed to be locked.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passage ways are lit.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 111.2 degrees F. There was enough clean linen available in the closets.

Medications-LPA observed medication cart to be locked and inaccessible to residents. There were two ( 2) complete first aid kits located in an office adjacent to the kitchen.

No deficiencies are cited at this time. Exit interview conducted. A copy of this report was issued and signature obtained.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2021

LIC809 (FAS) - (06/04)

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