197606498-4-4-2022-31-AS-TSMH-CD6UXK-20220404155829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606498
Report Date: 04/04/2022
Date Signed: 04/04/2022 03:58:40 PM

Document Has Been Signed on 04/04/2022 03:58 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:	GEYSER HOME		FACILITY NUMBER:	197606498
ADMINISTRATOR:	EDITHA C. TAGUM		FACILITY TYPE:	740
ADDRESS:	9539 GEYSER AVENUE		TELEPHONE:	(818) 718-0597
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS:	DATE:	04/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Edith Tagum		TIME COMPLETED:	03:55 PM

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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced annual/infection visit to this facility. LPA was greeted by facility staff Salve Pagun, who was observed wearing a mask. LPA temperature taken upon entry. LPA informed staff the purpose of this visit. The administrator was called at 10:15 AM and arrived later.

LPA reviewed files for all residents and staff between 11:30 am-1:00 pm. Resident files included current medical assessments, physician orders for medications and centrally stored medication logs. Medications are given as prescribed. LPA reviewed files for staff at the facility. Staff files included current first aid and CPR certifications as well as sufficient training documentation. All staff have criminal record clearance, and all are associated to this facility.

LPA conducted a tour of the physical plant between 1:00-2:00 PM to ensure there are no health and safety hazards and facility is following Title 22 Regulations.

The living area had furnishings and sufficient lighting and observed adequate seating for residents. Smoke alarms and carbon monoxide detectors were present and function properly. Fire extinguisher current with attached receipt.

There were 5 bedrooms designated for residents' use. All bedrooms were clean, properly furnished and had sufficient lighting. There were three bathrooms designated for residents' use. All bathrooms were clean, properly supplied and had functional fixtures. The water temperature range was between 105.1- and 120.0-degrees Fahrenheit.

LPA was escorted to kitchen/dining combination area. The area was clean and well kept.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

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: GEYSER HOME	FACILITY NUMBER: 197606498
	VISIT DATE: 04/04/2022

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(Cont from 809)

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the four (4) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk and eggs observed. The freezer is stocked with meats, poultry, and frozen vegetables. LPA observed on side of kitchen to the left of refrigerator is the staff room.

There is a supply of canned foods, dried foods, and extra paper towels and water in the garage including a sufficient supply of linens and PPEs.

The medications are locked in upper kitchen cabinet with the sharps locked in kitchen drawer below medication cabinet. LPA checked first aid kit and the first aid kit was sufficiently stocked. The cleaning supplies were locked in garage.

The grounds, entry/exits, and patio area were clean and free of obstruction.

There are no deficiencies to report. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

LIC809 (FAS) - (06/04)

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