197606449-12-8-2021-31-AS-ADUA-C9J4A9-20211208175535

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606449
Report Date: 12/08/2021
Date Signed: 12/08/2021 05:56:18 PM

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:	D' ELDERS "R" US		FACILITY NUMBER:	197606449
ADMINISTRATOR:	REBECCA V. LIM		FACILITY TYPE:	740
ADDRESS:	21514 ALAMINOS DRIVE		TELEPHONE:	(661) 513-1336
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91350
CAPACITY:	6	CENSUS: 5	DATE:	12/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:51 PM
MET WITH:	Ruskie Ragasa, Administrator		TIME COMPLETED:	04:30 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) Abeye Duguma met with the Administrator Ruskie Rajasa for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 2:00pm and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in the backyard. The facility has sufficient stock of PPE in a storage closet located near the front entrance. The facility has a total of six (06) bedrooms, of which five (05) are for residents and one (01) is for staff. The facility has two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) non-ambulatory and a hospice waiver for one (01). The facility is currently occupying five (05) non-ambulatory residents of which two (02) are under hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility has a swimming pool/body of water which is gated and locked. The garage is being used for laundry and storage. Laundry detergents, cleaning agents and other toxins are stored in a locked storage room located in the garage. Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

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: D' ELDERS "R" US	FACILITY NUMBER: 197606449
	VISIT DATE: 12/08/2021

NARRATIVE

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Knives and sharps are observed to be locked in a kitchen drawer inaccessible to residents. 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 77°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Facility has automatic fire doors and sprinkler system. Fire extinguisher is located in the kitchen, observed to be full and last inspected on 01/29/2021. Staff rooms were observed to be locked and located near the front entrance. No medications are observed in the staff room. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways are well lit. Clients have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 105.2°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinet. LPA observed medication and first aid kit to be locked and inaccessible to residents, located in a storage cabinet near the dining area.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2021

LIC809 (FAS) - (06/04)

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