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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606977
Report Date: 07/23/2024
Date Signed: 07/23/2024 04:19:15 PM


Document Has Been Signed on 07/23/2024 04:19 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:ALTA VISTA RCFE IIFACILITY NUMBER:
197606977
ADMINISTRATOR:MARY M. ESPARRAGOFACILITY TYPE:
740
ADDRESS:1204 N. LOUISE STREETTELEPHONE:
(818) 281-3234
CITY:GLENDALESTATE: CAZIP CODE:
91207
CAPACITY:6CENSUS: 3DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Mary M. Espararrgo, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced annual required visit. LPA met with Administrator Mary Esparrago and explained the reason for the visit. LPA inspected the physical plant, observed food supply, and reviewed resident and staff files. The facility is licensed for six (6) residents over the age of 60, with a hospice waiver for six (06) residents.

There is only one entrance being utilized at the facility. LPA inspected the interior and the exterior of the facility with Administrator Mary Esparrago including but not limited to: the living room, dinning room, staff / storage room, kitchen, four (4) resident bedrooms, two (2) bathrooms, laundry area and backyard. All indoor and outdoor passageways were observed to be free from obstruction. There is no body of water.

Bathrooms and bedrooms were observed to be clean and in good repair. There is a locked storage area for medications and toxins in the kitchen which is inaccessible to residents. Laundry area is located in the back of the kitchen. The kitchen was toured. All appliances were operating properly. There was a sufficient amount of perishable and non-perishable food. Kitchen knives and sharps are stored in a locked drawer in the kitchen. The common areas including the living room and dining room are clean and have the required furniture. The temperature was comfortable. The backyard has a shaded sitting area.

All resident bedrooms were toured. Each bedroom has a smoke detector, a bed, linens, a dresser, a lamp and sufficient closet space. Both bathrooms were toured. Bathrooms have the required grabs bars and non-skid mats. The hot water was 117.2 degrees which is within the required 105 - 120 degrees. LPA observed a fire extinguisher near the kitchen which was fully charged and last serviced on February 2024. Smoke detectors were observed throughout the facility. First-aid Kit is complete and located in the kitchen.

LPA reviewed residents files to confirm emergency contact information has been updated. LPA also reviewed staff files to confirm health screenings and fingerprint clearances. All staff files reviewed were fingerprint cleared.


Continue of 9099-C
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ALTA VISTA RCFE II
FACILITY NUMBER: 197606977
VISIT DATE: 07/23/2024
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No health or safety issues noted at the time of this visit.

Exit interview conducted and a copy of the report was issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024
LIC809 (FAS) - (06/04)
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