197603849-10-4-2024-29-AS-SURA-D9QMGU-20241004093627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603849
Report Date: 10/03/2024
Date Signed: 10/04/2024 09:37:12 AM

Document Has Been Signed on 10/04/2024 09:37 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MANOR CARE FACILITY		FACILITY NUMBER:	197603849
ADMINISTRATOR:	SOMERA, ERLINA		FACILITY TYPE:	740
ADDRESS:	7768 ALLOTT AVE.		TELEPHONE:	(818) 785-7047
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91402
CAPACITY:	4	CENSUS: 5	DATE:	10/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:01 AM
MET WITH:	Erlina Somer		TIME COMPLETED:	03:50 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) Sandra Urena arrived at the facility unannounced to conduct a required annual visit. At 11:05 a.m., the LPA was greeted by the staff, and the LPA explained the reason for the visit. The staff contacted the Administrator on the phone, and the Administrator arrived shortly thereafter. At 11: 10 p.m., the LPA, along with the Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. At 11: 45 a.m., the LPA observed five (5) residents at the facility at the time of the inspection. The facility is licensed for four (4) residents. The LPA conducted residents’ interviews. Per the resident, the resident stated that they were brought to this facility for a few days (a week), and that they were going to be moved to another house in San Diego, CA. At the time of the inspection, the LPA observed a staff person from a congregate house arrive at the facility to pick up the resident not admitted to this facility. Per the staff, they were moving the ‘resident’ to another congregate house. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last purchased on 10/10/2023. Exit has functioning auditory devices; however the devices were turned off. The fire alarm/ carbon monoxide detectors were tested and functioned properly. Medications and first aid kits are located in a locked cabinet near the kitchen. Laundry units are located inside laundry room near the kitchen area. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away inside the laundry room cabinets. KITCHEN: The LPA observed the kitchen/dining area. Knives were observed in two unlocked kitchen drawers, and a pair of sharp scissors on top of the kitchen counter top. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: MANOR CARE FACILITY	FACILITY NUMBER: 197603849
	VISIT DATE: 10/03/2024

NARRATIVE

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BEDROOMS: The facility is a single-story residential home with five (5) bedrooms, three (3) for resident use and two (2) for staff use. The LPA observed residents’ bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are five beds. Room number three closet is blocked by one bed. The bed will need to be removed, as the facility is only licensed for four (4) residents. The staff's bedroom door, at the end of the hallway (next to room#3), was observed to be unlocked, and it was observed to have many personal items and other items, potentially dangerous for residents in care. Inside temperature was maintained at a comfortable level. Bedroom #2 was observed to have a camera monitor. The Administrator removed the camera monitor at the time of the inspection.

RESTROOMS: Restroom is relatively clean and sanitary and in operating condition with grab bars and non-skid mats. The sinks had sufficient liquid soap, and paper towels. The LPA observed the staff’s bathroom to be unlocked and accessible to residents in care. The restroom had personal grooming items (razors) and chemicals accessible to residents in care.

OUTDOOR SPACE: At 11:45 a.m., the LPA observed the backyard to be unavailable to residents in care due to construction, furthermore the front yard area did not have a shaded area for residents’ use. The front of the facility did not have a ramp accessible for residents to exit to the front yard and have outdoor time. Both sides (left and right) passageways to the facility were obstructed at the time of the visit. The LPA had a conversation with the Administrator regarding the construction taking place in the backyard without a permit. The administrator stated that they had informed (verbally) the department about the construction. The LPA informed the Administrator about informing the department through an official letter and to provide proof of a building permit.
PATIO ROOM: The LPA observed a patio area next to the living room. The LPA observed a gas hotplate, and which was observed to be warm. The Administrator stated that the hot plate is used to cook meals that may give a strong odor to the rest of the house. The patio was observed to have many items that pose an immediate danger to residents in care. There are no bodies of water on the premises. A detached garage was observed. The garage door was unlocked and potentially accessible to residents in care.

Due to time constraints, LPA Urena will return on another date to complete the Annual inspection.

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2024

LIC809 (FAS) - (06/04)

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