197607355-2-28-2022-31-AS-RVAA-CC3TYL-20220228140854

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607355
Report Date: 02/28/2022
Date Signed: 02/28/2022 02:09:03 PM

Document Has Been Signed on 02/28/2022 02:09 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:	THREE SYCAMORES ON GOULD		FACILITY NUMBER:	197607355
ADMINISTRATOR:	MARK YULE		FACILITY TYPE:	740
ADDRESS:	4701 GOULD AVENUE		TELEPHONE:	(818) 890-6111
CITY:	LA CANADA	STATE: CA	ZIP CODE:	91011
CAPACITY:	6	CENSUS: 5	DATE:	02/28/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:03 AM
MET WITH:	Mark Yule, Administrator		TIME COMPLETED:	02:00 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) Rosaura Valenzuela conducted an unannounced Required One (1) year Infection Control inspection to the facility. LPA met with Administrator Mark Yule and explained the reason for the visit. A tour of the physical plant was conducted at 10:03am and the following was noted: There is only one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, and masks are available. LPA was screened upon entry. The facility had submitted and approved Mitigation Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has five (05) bedrooms and three (03) bathrooms currently occupying five (5) residents. One (01) room is a shared room and four (04) rooms are private rooms. (continued on LIC 809-C

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

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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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: THREE SYCAMORES ON GOULD	FACILITY NUMBER: 197607355
	VISIT DATE: 02/28/2022

NARRATIVE

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Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 71 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguishers are located in the kitchen,

The backyard of the facility has outdoor furniture with a covered shaded area for residents. There is no body of water at the facility. There is also a shed at the backyard being used as equipment storage.

Laundry area is located in the back of the facility, laundry detergents, cleaning agents and other toxins were observed to be locked.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the shower and toilet. The hot water temperature was measured at 105 degrees. There was enough clean linen available in stock at the cabinet.

Medications-LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. There is one (01) complete first aid kit.

Exit interview conducted. A copy of this report was issued and signature obtained.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura Valenzuela	TELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2022

LIC809 (FAS) - (06/04)

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