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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604761
Report Date: 06/14/2022
Date Signed: 06/14/2022 11:01:18 AM

Document Has Been Signed on 06/14/2022 11:01 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:FOUNTAIN SPRINGS INC. DBA FOUNTAIN SPRINGS ADULTFACILITY NUMBER:
197604761
ADMINISTRATOR:GEORGE KARAPANIAN/CRIS DESFACILITY TYPE:
735
ADDRESS:15457 BLEDSOETELEPHONE:
(818) 822-6906
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 4CENSUS: 4DATE:
06/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Christine DestajoTIME COMPLETED:
11:15 AM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. Upon arrival, LPA observed (2) staff and (2) clients in the front yard of the property. LPA was greeted and staff were informed the reason of the visit. There have not been any active or past COVID cases at the facility, and all (4) clients, including all staff are vaccinated and have booster shots. The current census is (4). LPA’s temperature was immediately taken and documented; a list of COVID-19 questions was asked; and LPA signed in the visitor book. LPA observed staff to have full mask covering; a hand sanitizing station; PPE supplies in drawer; and COVID-19, CDC, Department of Public Health, and Licensing postings on the walls throughout the facility. The Administrator Christine Destajo was contacted and arrived to the facility. LPA discussed the mitigation plan that was submitted and approved.

The infection control inspection began with the staff Roger Tison and concluded with Administrator Christine. The facility has (4) bedrooms; with (1) shared room, (2) private, and (1) staff room. All bedrooms were properly furnished. The common areas were observed to be clean, including bathrooms, with soap and towels. LPA conducted a mitigation plan review with the Administrator, to obtain information on how the facility has implemented the plan. The Administrator reported to LPA, that all staff and clients are vaccinated and recently obtained the booster shot. They no longer conduct COVID testing. Any new employee hires have the option to not be vaccinated; but will have to participate in weekly COVID testing. Administration continues to conduct training to staff in relation to COVID-19. Administrator reported the facility receives departmental emails, and participates with the informational calls. There is a paid sick leave policy in place. There are designated rooms for potential positive COVID clients. PPE, chemicals, cleaning supplies, emergency food and water, personal hygiene supplies, and paper products are stored in a locked closet.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/14/2022
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: FOUNTAIN SPRINGS INC. DBA FOUNTAIN SPRINGS ADULT
FACILITY NUMBER: 197604761
VISIT DATE: 06/14/2022
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Currently, the facility has sufficient staff, and has back-up staff in place if needed.

The Administrator informed LPA that they continue to implement the best practices for their facility, which has kept them COVID-19 free. The facility is aware to report any changes with clients and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted with Administrator Christine.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 06/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2022
LIC809 (FAS) - (06/04)
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