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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604069
Report Date: 11/02/2022
Date Signed: 11/02/2022 11:54:37 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 11/02/2022 11:54 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:PORTER RANCH ALOHA IIFACILITY NUMBER:
197604069
ADMINISTRATOR:BRUCE R. PARTRIDGEFACILITY TYPE:
740
ADDRESS:20022 VINTAGE STTELEPHONE:
(818) 349-1055
CITY:CHATSWORTHSTATE: CAZIP CODE:
91311
CAPACITY:6CENSUS: 4DATE:
11/02/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:17 AM
MET WITH:Bruce PartridgeTIME COMPLETED:
12:05 PM
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On 11/02/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced annual inspection. Upon arrival LPA met with staff and later with Administrator Bruce Patridge. The purpose of the visit was explained.

A physical plant tour was conducted at 11:20 a.m and the following was observed:

Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Staff screened LPA for covid symptoms and took LPA’s temperature. Facility has sufficient PPE supplies for more than 30 days. Food Inspection/Kitchen: LPA observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers in the kitchen. Sharps are centrally stored in a locked area. Medication are centrally stored in a locked cabinet. Chemicals are locked and stored under the kitchen sink. Smoke detectors/carbon monoxide are located throughout the facility and are hardwired. Smoke detectors and carbon monoxide detectors were tested at approximately 11:33 a.m. and appear to be functional. Fire extinguishers were observed throughout the facility and are charged with a charge date of 04/05/22. Common Areas: All common areas were observed to be clean and properly furnished. Facility’s temperature at the time of the visit was 76 F. Resident Rooms: Facility has six (6) bedrooms of which all are designated for residents use. All six (6) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. All rooms have adequate lighting and furniture. Bathrooms: There are three (3) bathrooms in the facility. LPA observed all bathrooms to be cleaned. The hot water was tested and measured 113.7 F, which is in regulation. Grab bars and non-skid mats were observed. (Continue on 809-C)

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:
DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/02/2022
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: PORTER RANCH ALOHA II
FACILITY NUMBER: 197604069
VISIT DATE: 11/02/2022
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Garage: There is an attached garage that is used for storage and laundry area. The door has an auditory signal system when open and was functional when tested. Outside: LPA toured the outside area and observed appropriate outdoor furniture with a shaded covered area for residents. There are no bodies of water.

No deficiencies cited. Exit interview conducted. Report signed and delivered.

SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn MartinezTELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2022
LIC809 (FAS) - (06/04)
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