197607123-10-30-2023-31-AS-TSMH-CX4VBB-20231030161715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607123
Report Date: 10/30/2023
Date Signed: 10/30/2023 04:17:30 PM

Document Has Been Signed on 10/30/2023 04:17 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:	ENCINO LIVING		FACILITY NUMBER:	197607123
ADMINISTRATOR:	O. ALMANY & D. PETRASEK		FACILITY TYPE:	740
ADDRESS:	16710 MAGNOLIA BLVD.		TELEPHONE:	(818) 907-1343
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	6	CENSUS: 6	DATE:	10/30/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:58 AM
MET WITH:	Anna Fabregas		TIME COMPLETED:	04:30 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 (LPAs), Tihesha Smith and Gina Saucedo conducted an unannounced Required 1-year inspection at this facility at approximately 11:57 am. LPA disclosed to staff the purpose of the visit. The Administrator was contacted. Staff authorized to signed. LPAs conducted a tour of the physical plant at approximately 12:30 pm to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Common areas were observed for the ability to safely serve the needs residents. These included the loving, dining room combination, and kitchen. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be clean, sanitary and have adequate seating for residents. LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen foods. Food pantry in kitchen stocked with can goods and boxed foods. Sharps are stored in kitchen drawer. Sharps observed to be locked and inaccessible to residents in care. First aid kits stored in upper cabinets in living room. Toxins are stored and locked under kitchen sink and observed to be locked an inaccessible to residents. There is one (1) fire extinguisher in the facility attached to the kitchen wall; observed to be charged. Laundry room is located at the back of the kitchen. The appliances observed to be functional. The locked cabinets above washer and dryer contain laundry detergents, toxins, and supplies. (Cont. to 809

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ENCINO LIVING	FACILITY NUMBER: 197607123
	VISIT DATE: 10/30/2023

NARRATIVE

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(Cont. from 809C)

The facility has a total of six (6) bedrooms, six (6) bathrooms for residents in care, and one (1) main bathroom. There is also an office

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the seven (7) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 105.3, 107.2, 108. 108.7, 109.2, 110.8, and 115.3 -degrees Fahrenheit.

Backyard has the following: Covered patio with tables and chairs. Patio furniture observed to be in good repair with adequate seating for residents.

No Garage at the facility

Smoke detector/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards.

At approximately 1:10 pm- 335 pm LPA reviewed three (3) resident files. Resident files included admissions agreements, assessments, personal rights. Three (3) random staff files reviewed. Staff files had clearances and current First aid and CPR.

Exit Interview Conducted /Copy of the Report Issued

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 10/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2023

LIC809 (FAS) - (06/04)

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