197606826-2-17-2022-31-AS-TSMH-CBR4ER-20220217180247

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606826
Report Date: 02/17/2022
Date Signed: 02/17/2022 06:02:56 PM

Document Has Been Signed on 02/17/2022 06:02 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:	ANGELS OF THE VALLEY BOARD & CARE		FACILITY NUMBER:	197606826
ADMINISTRATOR:	YANA D. DIAZ		FACILITY TYPE:	740
ADDRESS:	10700 RESEDA BLVD.		TELEPHONE:	(818) 831-0058
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91326
CAPACITY:	6	CENSUS: 2	DATE:	02/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:32 AM
MET WITH:	Yana Diaz		TIME COMPLETED:	05:06 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) Tihesha “Lynn” Smith conducted an unannounced Required - 1 Year annual visit to the above facility. Upon arrival LPA met with administrator Yana Diaz who was observed wearing a mask. LPA conducted a tour at 11:15 AM of the physical plant to ensure there are no health and safety hazards and facility following Title 22 Regulations The facility has six (6) interconnected smoke alarms and carbon monoxide alarms that are hard wired and battery operated. All smoke alarms were tested and function properly. The carbon monoxide detector was tested and functions properly. The fire extinguishers were current with receipt. Administrator confirmed there are two (2) residents residing in the facility. The living/dining combination area had sufficient lighting, adequate seating, was clean and properly furnished. The kitchen appeared clean, the appliances and fixtures were functional. The kitchen food supply was observed and sufficient for the two (2) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk and eggs observed with water and juices. The two kitchen freezers were stocked with meats and frozen vegetables. The locked garage stocked was stocked with non-perishable food, canned goods, water and PPEs. The sharps are locked in a drawer next to sink. The resident’s medications are locked in kitchen top cabinet near kitchen sink and first aid kit attached to cabinet door next to the medication cabinet.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
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: ANGELS OF THE VALLEY BOARD & CARE	FACILITY NUMBER: 197606826
	VISIT DATE: 02/17/2022

NARRATIVE

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Cont From 809)

The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. There were enough linens for resident use.

LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have enough supplies for personal hygiene. LPA measured the hot water between the required limit of 105-120 degrees Fahrenheit during time of visit. The cleaning supplies were locked in a cabinet under the main bathroom sink.

There was a shaded area with proper furniture for outdoor use.

LPA interviewed Resident 1 (R1) who reveals satisfied with food service, care, and treated well by staff.

LPA reviewed resident files files at 3:30 p.m but due to time constraints, LPA was unable to complete resident and staff file review and complete the Annual Inspection. Yana Diaz was informed that a subsequent visit will be conducted to review the records and complete the annual inspection.

Exit Interview Conducted / A Copy of the Report emailed

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