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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607223
Report Date: 07/13/2022
Date Signed: 07/13/2022 12:27:50 PM


Document Has Been Signed on 07/13/2022 12:27 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754



FACILITY NAME:ARDENVILLE HOME CARE IFACILITY NUMBER:
197607223
ADMINISTRATOR:VICENTE A. ROBLESFACILITY TYPE:
740
ADDRESS:7747 SHADYCOVETELEPHONE:
(818) 767-6054
CITY:BURBANKSTATE: CAZIP CODE:
91504
CAPACITY:6CENSUS: 5DATE:
07/13/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Vicente Robles, AdministratorTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual inspection with the focus of the Infection Control domain. LPA arrived unannounced and met with Administrator, Vicente Robles. The licensee, Arden Robles, arrived shortly thereafter. There are currently 5 non-ambulatory residents residing at the home.

LPA toured the facility and observed the following:
* The facility has 6 bedrooms, 3 bathrooms, living room, kitchen, dining room, laundry area, and a detached garage. Each bedroom is equipped with the required furnishings.
* Each resident has his/her own room and facility is able to designate a bathroom in the event of a positive COVID-19 case.
* There are no pools or bodies of water at the premises.
* COVID-19 signage are posted throughout the facility. LPA advise to add the cough/sneeze etiquette inside the house.
* The facility screens and logs the temperature of visitors, staff, and residents.
* Knives and disinfectants are locked and inaccessible to clients.
* Food supplies of 2 day perishable and a week of non-perishable were observed.
* PPE supplies of at least 30 days are in storage.
* Emergency numbers and resident's information are up-to-date.
* LPA reviewed medications for all 5 residents and they are all given as prescribed.

Per licensee, they are continuing to follow the mitigation plan. They continue to clean and disinfect daily and more often for high touched surfaces.
LPA provided Technical Assistance on the N95 Respirator Fit Testing.

No deficiencies issued today. An exit interview was held and a copy of this report was given to the licensee.
SUPERVISOR'S NAME: Lisa HicksTELEPHONE: (323) 981-3972
LICENSING EVALUATOR NAME: Cynthia D ChanTELEPHONE: (323) 981-3370
LICENSING EVALUATOR SIGNATURE:
DATE: 07/13/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/13/2022
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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