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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606784
Report Date: 01/10/2024
Date Signed: 01/10/2024 03:26:50 PM


Document Has Been Signed on 01/10/2024 03:26 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:HERITAGE OF NORTHRIDGEFACILITY NUMBER:
197606784
ADMINISTRATOR:MIJARES, MARYANNFACILITY TYPE:
740
ADDRESS:19251 CALAHAN STREETTELEPHONE:
(818) 775-9806
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 4DATE:
01/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:MARYANN MIJARES- Administrator TIME COMPLETED:
01:37 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Administrator Maryann Mijares and explained the reason for the visit. At approximately 10:40 am, with the assistance of staff, LPA took a tour of the physical plant to ensure the health and safety of the residents are protected and that the physical plant complies with Title 22 Regulations. Required postings were observed in the entry area.
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 box in the kitchen. Properly labeled medications were locked in one cabinets of the living room cabinet. The fire extinguisher is located in the hallway with service date of September, 2023. Bedrooms: There were four (4) bedrooms designated for residents' use. Two (2) bedrooms are designated for private use, and two (2) room is shared. All four bedrooms, in use by residents, were properly furnished with appropriate bedding and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 102.8 and 103.6 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. Laundry Area: The laundry area is located near by the living room. Laundry cabinet was locked and thus laundry detergents were inaccessible to residents. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing forms.
Medications: Medication and Medication Records were reviewed 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 MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 01/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/10/2024
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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