197603936-8-8-2024-29-AS-EPEI-D7XT99-20240808143133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197603936
Report Date: 08/08/2024
Date Signed: 08/08/2024 02:31:40 PM

Document Has Been Signed on 08/08/2024 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
WOODLAND HILLS N.ASC, 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:	DATE:	08/08/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Aleksandra Vartapetova, Administrator		TIME COMPLETED:	02:45 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 Analysts (LPAs) Emily Peraldi and Erica Mosley arrived at the facility unannounced to conduct a required annual visit. At 9:45 a.m., the LPAs met with staff and explained the reason for it visit. At 10:42 a.m., the Administrator, Aleksandra Vartapetova arrived at the facility. At 10:08 a.m., the LPAs, along with staff, 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. KITCHEN: The LPAs observed the kitchen and dining area. Knives are stored in a locked kitchen drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:11 a.m., hot water measured at 105.4-degree Fahrenheit. Laundry room is located through the kitchen. Cleaning supplies are kept secured and inaccessible to residents in the laundry area. BEDROOMS: The facility is a single-story residential home with six (6) bedrooms and six (6) bathrooms for resident's use. The LPAs observed a staff room near the office area. The LPAs observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Between 10:18 a.m. and 10:29 a.m., hot water measured between 105.1 and 111.3-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Continued on LIC-809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: JUST LIKE HOME	FACILITY NUMBER: 197603936
	VISIT DATE: 08/08/2024

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
26
27
28
29
30
31
32

OUTDOOR SPACE: At 10:30 a.m., the LPAs observed the back patio which has a covered outdoor area for resident use. Passageways were free and clear from obstruction. A pool was noted in the back yard with a secured gate with a padlock.

COMMON AREAS: The LPAs observed common area to be relatively clean and properly furnished. The LPAs observed the fire extinguisher to be fully charged and purchased within the year. At 10:50 a.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Medications and first aid kit are located in a locked closet near the entrance.

Between 10:05 a.m. and 10:26 a.m., the LPAs conducted interviews with four (4) out of five (5) residents.

RECORD REVIEWS: Between 10:58 a.m. and 12:00 p.m., the LPAs conducted a file review for all residents and staff regularly scheduled and observed the following: Staff have current first aid and training documentation showing required training completed. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All files were in order.

Starting at 1:41 p.m., the LPAs conducted a review of medication and medication documentation with Administrator for five (5) out of five (5) residents.

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

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 08/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/08/2024

LIC809 (FAS) - (06/04)

Page: 2 of 2