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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604966
Report Date: 10/16/2023
Date Signed: 10/16/2023 02:54:44 PM


Document Has Been Signed on 10/16/2023 02:54 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:NORTHRIDGE GARDEN VILLAFACILITY NUMBER:
197604966
ADMINISTRATOR:ANITA ORTIZFACILITY TYPE:
740
ADDRESS:10926 RESEDA BLVD.TELEPHONE:
(818) 360-1333
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY:6CENSUS: 4DATE:
10/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Leonilla Arquisola- CaregiverTIME COMPLETED:
03:00 PM
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On 10/16/2023 Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by staff and explained the reason for the visit. Shortly after, LPA met with Back up Administrator Paul Apolinario. A tour of the physical plant was conducted at 10:40AM. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were stored in locked drawers and cabinets. Medications are locked in the kitchen cabinet. LPA observed fully stocked first aid kit in the kitchen cabinet. Laundry Area: located through the kitchen. Appliances observed to be in good repair. Door was locked and thus laundry detergents were inaccessible to residents. Temperature: Facility maintains a comfortable temperature of 77 degrees Fahrenheit. Surrounding Grounds: Entry/exits were observed to be locked. The outdoor area was clean and free of hazards .There is a pool observed to be enclosed by a fenced and locked. Storage rooms and garage observed in the backyard area. Smoke Alarms and Carbon Monoxide: There are 2 fire extinguisher located in the dining room, and kitchen observed to be fully charged and was purchased on 10/22/23. Bedrooms: the facility has six (6) bedrooms. Four (4) designated for residents use in which they were clean, properly supplied and had functional fixtures and two (2) for staff. Bathrooms: All bathrooms observed properly supplied; with grab bars and non-skid mats installed. LPA observed water temperature to be 114.4 degrees F. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed furnished appropriately. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.

No deficiencies issued during today’s visit. Report was signed and delivered and an exit interview was conducted

SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2023
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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