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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604780
Report Date: 11/22/2022
Date Signed: 11/22/2022 03:10:34 PM


Document Has Been Signed on 11/22/2022 03:10 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:VILLA MULHOLLAND IIFACILITY NUMBER:
197604780
ADMINISTRATOR:RIMMA GORDONFACILITY TYPE:
740
ADDRESS:4501 SAN FELICIANO DR.TELEPHONE:
(818) 348-3825
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91364
CAPACITY:6CENSUS: 6DATE:
11/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:Rimma Gordon - Administrator TIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. Upon arrival, LPA met with Administrator Rimma Gordon and explained the reason for the visit.

At approximately 1:30pm,  tour of the physical plant was conducted with Ms. Gordon.  The facility has seven (7) bedrooms and eight (8) bathrooms currently occupying (6)  residents on six (6) private bedrooms.  One (1) bedroom and one (1) bathroom is designated for the  staff use.  The facility is fire cleared for six (6) non-ambulatory residents, Hospice waiver for four (4).

Physical environment was checked for cleanliness and condition.  Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: 

Living and dining room furniture were also checked.   The living room is neat and clean along with the dining room.  The facility maintains a comfortable temperature at  73°F.  The smoke detectors / combo carbon monoxide detectors were tested and observed to be operational. The fire extinguishers appeared to be fully charged and last serviced on January 2022.

Food Service/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. LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. First aid kit is observed to be complete with tools and supplies.

Continued on 809
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: VILLA MULHOLLAND II
FACILITY NUMBER: 197604780
VISIT DATE: 11/22/2022
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Continued from 809

Resident bedrooms were properly furnished with a bed, night stand, 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 #3. LPA observed a sufficient supply of linen,  personal hygiene supplies, PPE, First aid kit and supplies stored at this location as well.

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 between 105 and 120 degrees Fahrenheit.  Towels and washcloths are not shared.  There is enough clean linen available in stock at the linen cabinet.

The backyard of the facility has outdoor furniture with a 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 was observed inaccessible to residents in care.   The garage also serve as storage for additional perishable and non-perishable  food,  other supplies and old equipment storage. There was an additional storage room in the garage and was observed used to fold clean laundry and store extra equipment and furniture for facility use. 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. 

The LPA spoke with Rimma regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate each bedroom as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if there are any covid-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time.
 
Exit interview conducted. Report issued and sent via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/22/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2