197603936-8-25-2023-29-AS-SURA-CV3377-20230825175925

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603936
Report Date: 08/25/2023
Date Signed: 08/25/2023 06:00:11 PM

Document Has Been Signed on 08/25/2023 06:00 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JUST LIKE HOME		FACILITY NUMBER:	197603936
ADMINISTRATOR:	ALEXSANDRA VARTAPETOVA		FACILITY TYPE:	740
ADDRESS:	12521 KILLION STREET		TELEPHONE:	(818) 769-9955
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 6	DATE:	08/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Alexandra Vartapetova		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct a required annual visit. The LPA was greeted by staff, the LPA explained the reason for the visit. The met Administrator Aleksandra Vartapetova arrived shortly after, the LPA explained the reason for the visit.

The LPA and the administrator toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Kitchen drawer containing knives was locked. Laundry room is located through the kitchen with access to a bathroom where cleaning supplies are kept. All items were appropriately secured at the time of the visit.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six (6) designated residents’ rooms with single occupancy. A sufficient supply of extra towels and linens was observed.

RESTROOMS: Resident restrooms were clean and sanitary with grab bars and non-skid surfaces.

COMMON SPACES: The facility maintained a temperature of 76 degrees. Living room and dining furniture were observed to be in good condition. Required postings were observed at the entrance.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for residents’ use. A pool was noted in the back yard, the gate was secure with a padlock. The garage is where the seven-day were the emergency supplies are found.

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SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: JUST LIKE HOME	FACILITY NUMBER: 197603936
	VISIT DATE: 08/25/2023

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RECORDS: Records review began at 12:30 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order. MEDICATIONS: Medications were observed to be locked in closet by the hallway. Medications review began at 2:30 p.m.; medications are labeled and checked for expiration dates. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The LPAs discussed the new PIN changes regarding infection control.

The LPA obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2023

LIC809 (FAS) - (06/04)

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