197604761-7-23-2023-31-AS-JGTN-CTZQT3-20230723122627

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604761
Report Date: 07/23/2023
Date Signed: 07/23/2023 12:27:11 PM

Document Has Been Signed on 07/23/2023 12:27 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FOUNTAIN SPRINGS INC. DBA FOUNTAIN SPRINGS ADULT		FACILITY NUMBER:	197604761
ADMINISTRATOR:	GEORGE KARAPANIAN/CRIS DES		FACILITY TYPE:	735
ADDRESS:	15457 BLEDSOE		TELEPHONE:	(818) 822-6906
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY: 4		CENSUS: 4	DATE:	07/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:42 AM
MET WITH:	Cristina Destajo - Co Administrator		TIME COMPLETED:	12:30 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	A Required One (1) year visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with administrator Cristina Destajo. Purpose of visit was stated. LPA observed that the four (4) residents were at the facility during visit. This facility is North Los Angeles Regional Center vendored facility Level IV-I. A tour of the physical plant was conducted at 9:10 AM and the following was noted: The facility has a gate outside before getting into the facility. The only entrance being utilized is the main front door, there is a sign at the main door that everyone entering at the facility must wear mask. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Control Plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. Facility has five (5) bedrooms and two (2) bathrooms. One bedroom is designated as an office and another one is designated as a staff bedroom. One (1) bathroom is designated for staff use. There is no body water in the facility. (continued to LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2023

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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: FOUNTAIN SPRINGS INC. DBA FOUNTAIN SPRINGS ADULT	FACILITY NUMBER: 197604761
	VISIT DATE: 07/23/2023

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

(continued from LIC 809)

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature measured at 107.4°F and within the required range.
Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. All the toxins, cleaning solutions and disinfectants are locked in the laundry area cabinet.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat is observed to be within the required range.
Fire extinguisher. There are two (2) fire extinguisher in the facility: one (1) in the kitchen, one (1) in the hallway of the living room. Extinguishers were observed to be operable and last checked on 07/14/23. Smoke alarms are hardwired and interconnected. Carbon monoxide and smoke alarms were tested and observed to be operable. There is no garage at the facility only driveways. There is an additional dwelling unit (ADU) at the backyard. There is also a tool shed where other toxins and tools were kept. The shed was observed to be locked during visit. Laundry area is located adjacent to the kitchen. Laundry detergents and other cleaning agents and toxins are kept locked in the cabinet in the laundry area. Knives and sharps were kept in a kitchen cabinet. Medication was observed to be inaccessible and stored in a secured medication cabinet. There is a complete First Aid kit in the medication cabinet. Staff and clients records are reviewed and appeared to be complete and updated.

Disaster drill was last conducted on 06/20/23. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2