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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607214
Report Date: 10/10/2023
Date Signed: 10/10/2023 03:34:59 PM

Document Has Been Signed on 10/10/2023 03:34 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:RIDGEWOOD RESIDENTIAL CARE HOME #2FACILITY NUMBER:
197607214
ADMINISTRATOR:MARY ANNE L. ALCASIDFACILITY TYPE:
735
ADDRESS:9237 RUBIO AVENUETELEPHONE:
(818) 335-2771
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY: 4CENSUS: 4DATE:
10/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:35 AM
MET WITH:Rowena CruzTIME COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPAs), Tihesha Smith and Gina Saucedo conducted an unannounced Required 1-year inspection at this facility 10:35 am. LPA disclosed to the administrator the purpose of the visit.

LPA conducted a tour of the physical plant at approximately 11:10 am 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 kitchen/dining room combination, living room and sitting room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to 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 four (4) residents currently residing there. Two (2) days of
perishable food observed. The freezer is stocked with meats and frozen vegetables. Food pantry located in laundry room. Resident medications and two (2) stocked first aid kits stored in large cabinet in laundry area. Medications observed to be locked and inaccessible to residents in care. Toxins are stored and locked in laundry room in wardrobe cabinet. The cabinet containing the toxins observed to be locked and inaccessible to residents.

The sharps are stored in locked metal cabinet in laundry room. There is one (1) fire extinguisher attached to wall in the kitchen and observed to be charged.

Laundry room is located across from garage door. The appliances observed to be functional.
(Cont. from 809)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2023
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: RIDGEWOOD RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 197607214
VISIT DATE: 10/10/2023
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The facility has a total of six (6) bedrooms and two (2) bathrooms: Four (4) rooms for residents. Two (2) rooms for staff. Facility sketch only indicates one (1) staff room.

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, mattress pads, and blankets. LPA observed a supply of linens in hall closet.

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 two (2) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was between 113.0- and 113.1 -degrees Fahrenheit.

Backyard has the following: Covered patio with picnic bench/table combination. Patio furniture observed to be in good repair.

Attached Garage: Used for PPEs and storage.

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

Facility grounds were free of hazards.

At approximately 12:48 pm and 2:40 pm, LPAs reviewed three (3) staff files. Staff files had the appropriate trainings to include First aid and CPR. Four (4) out of four (4) resident files included medical assessments and needs and services plans.

Deficiencies cited on 809-D

Exit Interview Conducted /Appeals/Copy of the Report Issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 10/10/2023 03:34 PM - It Cannot Be Edited


Created By: Tihesha Smith On 10/10/2023 at 02:11 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: RIDGEWOOD RESIDENTIAL CARE HOME #2
FACILITY NUMBER: 197607214

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/10/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87305

Prior to constructions or alterations all facilities shall obtain a building permit
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above in 1 out of [1 facility constructions which poses an immediate health, safety or personal rights risk to persons in care.Wi
POC Due Date: 10/11/2023
Plan of Correction
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Within 24 hrs the Licensee will provide a written plan of action explaining the steps they will take to bring the physical plant into compliance.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Naira Margaryan
LICENSING EVALUATOR NAME:Tihesha Smith
LICENSING EVALUATOR SIGNATURE:
DATE: 10/10/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/10/2023


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