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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607284
Report Date: 11/01/2021
Date Signed: 11/01/2021 11:28:20 AM

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:LIFESTYLE HOME CARE FOR SENIORSFACILITY NUMBER:
197607284
ADMINISTRATOR:BIENVENIDA B. GOUDEAUXFACILITY TYPE:
740
ADDRESS:11734 DORAL AVENUETELEPHONE:
(818) 368-5108
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY:4CENSUS: 2DATE:
11/01/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Bienvenida GoudeauxTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Wendell Smith made an unannounced Required annual visit to the above facility. Upon arrival, LPA met with administrator Bienvenida Goudeaux and the reason for the visit was explained.
A tour of the physical plant was conducted with administrator between upon entry to the facility; the LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted:
Smoke detectors and Carbon Monoxide detectors were tested and functioned properly during time of visit. Fire extinguishers were observed to be fully charged.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a locked drawer.
Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.
Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. LPA measured the hot water between the required limit of 105-120 degrees Fahrenheit during time of visit.
Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. All common areas were appropriately furnished and furniture was in good condition.
Surrounding Grounds (Outdoors): LPA observed the pool to be locked and inaccessible to residents in care. LPA observed the rest of the backyard to be free of clutter and debris. Exit Interview conducted.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Wendell SmithTELEPHONE: (818) 738-4525
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2021
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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