197604780-12-18-2024-29-AS-ZCHN-DC3M87-20241218082239

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604780
Report Date: 12/04/2024
Date Signed: 12/18/2024 08:23:44 AM

Document Has Been Signed on 12/18/2024 08:23 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLA MULHOLLAND II		FACILITY NUMBER:	197604780
ADMINISTRATOR/ DIRECTOR:	RIMMA GORDON		FACILITY TYPE:	740
ADDRESS:	4501 SAN FELICIANO DR.		TELEPHONE:	(818) 348-3825
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91364
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	12/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Rimma Gordon		TIME VISIT/ INSPECTION COMPLETED:	05:30 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	Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with staff and explained the reason for the visit. Administrator was contacted and arrived shortly. LPA and staff toured the physical plant areas: The facility has seven (7) bedrooms and eight (8) bathrooms currently occupying six (6) resident private bedrooms. One (1) bedroom and one (1) bathroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory residents, Hospice waiver for six (6). There is a dedicated area for the posting of required documents directly by the main entrance and hallway. All resident bedrooms observed properly furnished with a bed, night stand, chair and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Extra linens are kept in cabinets in the hallway nearest bedroom. LPA observed a sufficient supply of linen, personal hygiene supplies, PPE, First aid kit and supplies stored at this location as well. LPA observed staff bedroom to be inaccessible to residents at this time. The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured was within required range (112 degrees Fahrenheit. Living and dining room furniture were also checked. Dining room furniture were observed to be in good condition and appeared to be relatively clean. The facility maintains a comfortable temperature. The smoke detectors are hardwired and inter connected and observed to be operational. The fire extinguishers were fully charged and last serviced on 03/05/2024. Kitchen area was sufficiently stocked with perishable and non-perishable food properly stored. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be kept in a locked drawer to the left of the sink. (Continue to LIC 809c).

Desaree Perera	TELEPHONE: (818) 596-4347
Zabel Chochian	TELEPHONE: (818) 419-5440
	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

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: VILLA MULHOLLAND II	FACILITY NUMBER: 197604780
	VISIT DATE: 12/04/2024

NARRATIVE

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LPA observed the medication cabinet located next to the laundry area to be locked and inaccessible to residents. First aid kit is observed to be inaccessible to residents in care complete with tools and supplies. The common areas were observed to be properly furnished and relatively clean at the time of the visit.

The backyard of the facility has outdoor furniture with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility. The garage is attached to the home and has an additional space/room for staff to use for breaks. Licensee/Administrator agreed that this additional room/space in the garage will only be used as storage space. The garage also serve as storage for additional perishable and non-perishable food, other supplies and old equipment storage. The garage was observed to be inaccessible to residents in care. Laundry area is located along the kitchen hallway leading to the garage. Laundry detergents, cleaning agents and other toxins are kept in the locked cabinet in the laundry area.

Records review 12pm-3pm: LPA reviewed six (6) resident records for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. LPA requested that the training records be documented to show the actual time. All records were observed to be in order at this time.

Medications review began at approximately 3pm The medications are centrally stored in the medication cabinet located near the laundry room. Medications are properly documented on the centrally stored medications and destruction record.

No deficiencies cited during this visit. Exit interview was conducted and a copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 12/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/04/2024

LIC809 (FAS) - (06/04)

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