197606522-2-17-2022-31-AS-NRED-CBQV9H-20220217151421

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606522
Report Date: 02/17/2022
Date Signed: 02/17/2022 03:15:06 PM

Document Has Been Signed on 02/17/2022 03:15 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:	ANDREA'S ELDERLY RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	197606522
ADMINISTRATOR:	ANDY M. AGUILAN		FACILITY TYPE:	740
ADDRESS:	22901 CANTLAY STREET		TELEPHONE:	(818) 914-4254
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 3	DATE:	02/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Andy Aguilan		TIME COMPLETED:	03:25 PM

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At approximately 12:20 PM on 02/17/22, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection using the Infection Control Domain of the Compliance and Regulatory Enforcement (CARE) Tools. LPA met with Administrator and disclosed the reason for the visit.

Census: 3

The facility contained 5 bedrooms and 2 bathrooms, along with a garage, kitchen, dining room, office, and outdoor space.

Entry: At the main entrance, LPA observed signs regarding the facility’s COVID-19 policies, such as visitation, droplet precautions, and symptoms. LPA also observed recent Provider Information Notices and a sign indicating oxygen is in use. The facility monitors activities with surveillance cameras at the front and inside the facility.

Once inside, LPA observed a confidential complaint poster, house rules, ombudsman contacts, and personal rights poster. Also posted were more COVID-19 awareness signs such as cleaning procedures, cough etiquette, symptoms of COVID-19, social distancing, and droplet precautions.

Screening: Upon entry, LPA was screened for COVID-19 by staff. LPA recorded temperature, symptoms, and contact tracing information in a visitor log. LPA observed a screening station which contained 2 bottles of sanitizer, surgical masks, and gloves. LPA also observed a daily log for resident vital signs and temperature.

Bedrooms: The facility had 2 private bedrooms, 2 shared bedrooms and one staff bedroom. The staff bedroom was free from hazards. All resident bedrooms contained adequate storage space, clean linens, televisions, nightstands, and lights. The bedroom at the back side of the house, Bedroom #4, was designated for a bedridden resident. LPA observed a closet in the hallway between bedrooms with an adequate supply of clean linens and towels.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

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: ANDREA'S ELDERLY RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 197606522
	VISIT DATE: 02/17/2022

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Bathrooms: The facility had 2 bathrooms. Bathroom #1 is in the hallway by Bedroom #1 and Bedroom #2. Bathroom #2 was near the office. Bathroom #1 contained fully stocked paper towels, a trash can, a handwashing instruction sign, grab bars in the shower, and non-skid mats. Liquid soap is provided upon use by staff due to residents who lack hazard awareness. Bathroom #2 contained fully stocked soap, paper towels, handwashing instruction sign, and a trash can.

Common Area: All common areas, floors, and ceilings were clean. All furniture was in good repair. LPA observed adequate water supply near the dining room table along with a first aid kit. Medication and resident files were locked in cabinets.

Kitchen: LPA observed adequate supplies of perishable food in the fridge and non-perishable food in the pantries. Additional medication is locked above the kitchen. The kitchen has 2 doors which remain unlocked. The facility has 2 additional refrigerators with surplus food supplies.

Outside space: LPA observed a covered patio area with furniture in good condition. LPA also observed a well-maintained yard and a locked shed with tools and incontinence supplies inside. All pathways were free from debris and obstruction. A screen door by the office needed to be repaired.

Garage: LPA observed an unlocked locked garage with laundry machines and an additional refrigerator. Cleaning supplies were locked in a cabinet next to the laundry machines.

Safety: LPA observed Emergency Evacuation Plans with routes clearly labeled at the front entrance and in the hallway. A fire alarm was present at the front entrance. Smoke detectors in the hallway and bedrooms were functioning. 3 fully-charged fire extinguishers were located near the kitchen and garage. Water temperature tested in Bathroom #1 was 115.1 degrees Fahrenheit. The emergency exits path was clear and unlocked. The front door, back sliding door, and exit door in Bedroom #4 all had operating auditory alarms.

LPA conducted exit interview and issued report.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 02/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/17/2022

LIC809 (FAS) - (06/04)

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