197606348-12-4-2023-31-AS-LNCA-CY4NGN-20231201092722

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606348
Report Date: 11/30/2023
Date Signed: 12/04/2023 01:14:03 PM

Document Has Been Signed on 12/04/2023 01:14 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	COMMUNITY INTEGRATION ADC		FACILITY NUMBER:	197606348
ADMINISTRATOR:	PETER MEDVEDEV		FACILITY TYPE:	775
ADDRESS:	10100 BALBOA BL.		TELEPHONE:	(818) 772-1155
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 120		CENSUS: 148	DATE:	11/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Peter Medvedev- Administrator and Robert Erio- Program Director		TIME COMPLETED:	03:30 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) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with front desk Marlene Llanos and advised for the purpose of the visit. LPA met with Program director Robert Erio and administrator Peter Medvedev at 9:35am. At 9:45 am, with the assistance of program director, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational and their carbon monoxide detectors are not installed. There are three (3) fire extinguisher located within the facility and they are located: outside the kitchen (end of hallway), outside storage (beside staircase), and edge of common area, where the charge date is 8/23/2023. During the visit the facility is at 74 degrees Fahrenheit. Facility is licensed to serve adult and elderly individuals in less than 24 hour care. The facility is two (2) story building, the first (1st) floor is where the offices are located and common area where attendees do their program. The second (2nd) floor is inaccessible and lock to attendees and is kept only for storage and old equipment. The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. There are two (2) bathrooms designated for attendees to use. Bathroom (1) is located close to the entrance where attendees can used and is separated from males and females. Staff bathroom (2) that is separated from male and female as well is located in the staff area were properly supplied and had functional fixtures. Common bathroom hot water temperature was measured at 116.9 degrees Fahrenheit. Cleaning supplies are being stored in a locked cabinet under the staircase. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: COMMUNITY INTEGRATION ADC	FACILITY NUMBER: 197606348
	VISIT DATE: 11/30/2023

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The common areas were properly furnished with lots of tables and chairs to do activities such as: karaoke, arts and crafts, jewelry making, movies, circuit training, and exercises. Computer/ internet are also available for use in the common area. Dining table are adequate to accommodate all of the attendees. Office space is located at the edge of the facility, where staff and attendees records are kept. No medications are stored in the facility or office area.

Entry and exits were free of obstruction. LPA conducted a file review of resident records to ensure compliance of licensing forms. LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit interview conducted and a copy of the report issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 11/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/30/2023

LIC809 (FAS) - (06/04)

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