197606440-10-27-2022-31-AS-MCAA-CKLTHZ-20221027144535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606440
Report Date: 10/27/2022
Date Signed: 10/27/2022 02:45:41 PM

Document Has Been Signed on 10/27/2022 02:45 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PRECIOUS MOMENTS RETIREMENT HOME		FACILITY NUMBER:	197606440
ADMINISTRATOR:	ANNA FABREGAS		FACILITY TYPE:	740
ADDRESS:	7231 MADORA AVENUE		TELEPHONE:	(818) 341-0620
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 6	DATE:	10/27/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Dina Monzones, Daniel De Los Reyes		TIME COMPLETED:	03:00 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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Dina Monzones and Daniel De Los Reyes and explained the reason for the visit. At approximately 12:15pm, with the assistance of staff, LPA took a tour of the physical plant. Required postings, sign-in sheet, hand sanitizer and temperature check were observed in the entry area. The smoke alarms are battery operated and pull chord. The carbon monoxide detector functions properly. The fire extinguisher is located in the laundry area, that is adjacent to the kitchen. The charge date is 9/30/2022. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were six (6) total bedrooms. Five (5) rooms are designated for residents' use. The bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. One (1) bedroom is for staff use. Bathrooms: There are three (3) bathrooms designated for residents' use, which were properly supplied and had functional fixtures. Hot water temperature was measured between 105 to 114 degrees Fahrenheit. No toxins, hazardous items, and cleaning supplies were observed accessible in any of the three bathrooms. Common Areas: These included the living room and dining area. The common areas were properly furnished. The floors were clean and maintained and the furniture was in good repair. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRECIOUS MOMENTS RETIREMENT HOME	FACILITY NUMBER: 197606440
	VISIT DATE: 10/27/2022

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Surrounding Grounds: Entry/exits for the front and back yards were free of obstruction. There is a covered patio and outdoor furniture in good repair and appropriate for outdoor use. There is a locked storage space where staff maintains cleaning supplies. This was observed inaccessible to the residents in care. The laundry area and detergents are located adjacent to the kitchen. Detergents were locked and inaccessible.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2022

LIC809 (FAS) - (06/04)

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