197603823-1-14-2023-31-AS-JGTN-CN3UEX-20230114143151

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603823
Report Date: 01/14/2023
Date Signed: 01/14/2023 02:31:56 PM

Document Has Been Signed on 01/14/2023 02:31 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:	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: 27	DATE:	01/14/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Maria Heredia - Staff		TIME COMPLETED:	02:30 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) Gary Tan conducted an unannounced Required One (1) year - Infection Control inspection at this facility. LPA met with staff Maria Heredia who called the administrator and explained the reason for the visit. The administrator designated Maria Heredia to sign the report. A tour of the physical plant was conducted at 9:30 AM 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. All the staff were observed to be wearing mask. The facility had submitted and approved Mitigation Plan and Infection Control 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 multiple screening stations all through out the facility. The facility has sufficient stock of PPE in the storage room. The facility has fifteen (15) bedrooms and nine (9) bathrooms in multiple interconnected residential type building. The facility is fire cleared for thirty (30) non-ambulatory residents, twenty three (23) of which maybe bedridden in rooms 1 to 15. Hospice waiver for ten (10) residents. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2023

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: 01/14/2023

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(continued from LIC 809)

Living and dining rooms furniture were checked. The living rooms were neat, clean and in proper order. The facility maintains a comfortable temperature at 75°F. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors installed in the facility. Fire extinguishers are located all throughout the facility and last inspected on 11/02/22. The facility is equipped with sprinkler system.

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 locked cabinet inaccessible to the residents.

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 a range of 108.3°F to 118.2°F. There were enough clean linen available in the closets.

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

Staff and residents records were reviewed and appeared to be complete and updated.

There is no health and safety issue observed during this visit. Exit interview conducted. A copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/14/2023

LIC809 (FAS) - (06/04)

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