197607065-12-12-2023-31-AS-LNCA-CYFUGT-20231212143452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607065
Report Date: 12/12/2023
Date Signed: 12/12/2023 02:34:57 PM

Document Has Been Signed on 12/12/2023 02:34 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:	BURBANK HILLS RESIDENTIAL CARE FACILITY		FACILITY NUMBER:	197607065
ADMINISTRATOR:	DINA ALGER		FACILITY TYPE:	740
ADDRESS:	425 UNIVERSITY AVENUE		TELEPHONE:	(818) 588-3122
CITY:	BURBANK	STATE: CA	ZIP CODE:	91504
CAPACITY:	6	CENSUS: 4	DATE:	12/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Dina Algar- Licensee		TIME COMPLETED:	02:45 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) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with licensee Dina Algar at 10:30am At 10:45 am, with the assistance of licensee, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational and their carbon monoxide detectors that functions properly. The fire extinguisher is in the hallway, kitchen, and common room and the charge date is 12/12/2023. During the visit the facility is at 71 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory. Kitchen: The kitchen is beside the common room. The kitchen is locked and only employees can enter the area. The kitchen appliances and fixtures were functional. The kitchen has a working electric stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Cleaning supplies are being stored in a locked cabinet in the lock laundry room beside the kitchen. Properly labeled medications were locked in the kitchen area cabinets in the office station. Bedrooms: There were three (3) bedrooms designated for residents' use. Three (3) of the bedrooms, in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Room #1, room #2 and #3 are properly furnished and occupied by shared residents. There is only one (1) resident for room #1 and room #3 for now. There are one (1) staff bedroom and that is locked with no medication in sight. Continue to LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BURBANK HILLS RESIDENTIAL CARE FACILITY	FACILITY NUMBER: 197607065
	VISIT DATE: 12/12/2023

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Bathrooms: There are two (2) bathrooms in the facility, but only one (1) bathroom is designated for residents' use. The bathroom were properly supplied and had functional fixtures. Bathroom #1 hot water temperature was measured at 119.2 degrees Fahrenheit and bathroom #2 is for staff used. Bathroom #1 is for residents and is located in the hallway between bedroom #2 and bedroom #3 is located in the hallway between room #2 and room #3. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

Common Areas: Office space/ staff room is beside the entrance of the facility. The common room includes the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6).

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area and detergents are located by the laundry room and is kept secured. The facility does not have a swimming pool or body of water. The garage is detached and is used for storage for incontinence for 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 compliance with licensing forms.

Medications: Medication and Medication Records (MMR) were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit interview conducted and a copy of the report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 12/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/12/2023

LIC809 (FAS) - (06/04)

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