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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606784
Report Date: 01/29/2024
Date Signed: 01/29/2024 03:32:09 PM


Document Has Been Signed on 01/29/2024 03:32 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:
01/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
02:26 PM
MET WITH:Mary Ann Mijares- AdministratorTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted unannounced visit to this facility in conjunction with a complaint control 31-AS-20240123154443. During the physical plant tour, LPA observed sharp objects are not locked in the lock box. Administrator locked sharp objects immediately. LPA also observed a gallon of roof paint in the hallway. Administrator stated that there was a leak on the roof and the painter had left the paint on the hallway entrance. LPA reminded Administrator that paint should be stored inaccessible to residents with dementia. Staff immediately locked the paint.

Exit interview conducted and deficiencies cited and copy of this report delivered
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2


Document Has Been Signed on 01/29/2024 03:32 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 NORTHRIDGE
FACILITY NUMBER: 197606784

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
01/29/2024
Section Cited
CCR
87705(f)(1)

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87705(f)(1) Care of persons with Dementia The following shall be stored inaccessible to residents with dementia:(1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).
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Administrator locked immediately the drawer.
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Based on observation, the licensee did not comply with the section cited above. LPA observed sharp objects drawer unlocked. This poses/posed an immedate health, safety or personal rights risk to persons in care.
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Type A
01/29/2024
Section Cited
CCR87705(f)(2)

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Care of persons with Dementia The following shall be stored inaccessible to residents with dementia:Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
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Staff locked immediately locked the gallon of piant.
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Based on observation, the licensee did not comply with the section cited above. LPA observed a gallon of roof paint in the entry hallway. This poses/posed an immedate health, safety or personal rights risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 01/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/29/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2