197607356-2-9-2022-31-AS-JMAZ-CBGT5H-20220209132533

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607356
Report Date: 02/09/2022
Date Signed: 02/09/2022 01:25:42 PM

Document Has Been Signed on 02/09/2022 01:25 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:	DE LA VEGA ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	197607356
ADMINISTRATOR:	EILEEN TAGDULANG		FACILITY TYPE:	735
ADDRESS:	17521 TUBA STREET		TELEPHONE:	(818) 366-3282
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY: 6		CENSUS: 5	DATE:	02/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	EILEEN TAGDULANG		TIME COMPLETED:	01:45 PM

NARRATIVE

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At 12:30 PM Licensing Program Analysts (LPAs) Melissa Ruiz and Joscelyn Martinez conducted an unannounced annual inspection at the facility mentioned above. LPAs were greeted by Administrator Eileen Tagdulang. This is a seven (7) bedroom and three (3) bathroom single story Adult Residential Home. A physical tour was initiated at 12:30 p.m. and observed the following:

Infection control: No infection control signs were observed outside the facility. LPAs reminded Administrator to place covid-19 signage outside the entrance. Upon entering the location, LPAs observed the sign in station which contained thermometer, hand sanitizer, and visitors sign in sheet. LPAs’ temperature were recorded. Sufficient PPE supplies were observed. Food Inspection: LPAs observed there to be sufficient stock of one-week non-perishable foods and two-day perishable foods. Food storage and preparation areas are clean and inaccessible to pests. At 12:45 P.M. sharps were observed on the dish rack and in an unlocked drawer, which were accessible to clients. Cleaning supplies are centrally stored in a designated room near the laundry room. Smoke detectors/carbon monoxide are dual hardwired throughout the facility. At 12:50 P.M alarms were tested and appear functional. Fire extinguisher has a date of purchase of 02/09/22. Client rooms: There are five (5) designated rooms for clients. LPAs were then escorted through the home and observed the client’s rooms to be properly furnished. Bathrooms: There are two (2) restrooms designated for clients LPAs observed the bathroom which contained paper towels, hand sanitizer, and trash cans with closed tight-fitting lids. The water temperature read 105.9 F. Outside areas: LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area. There is a body of water which is fenced and kept locked

Deficiencies were issued per CA code of Regulations Title 22 or Health and Safety Code. See 809D included with this report. Appeal rights issued. Report delivered. Exit interview conducted.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

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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Document Has Been Signed on 02/09/2022 01:25 PM - It Cannot Be Edited

Created By: Joscelyn Martinez On 02/09/2022 at 01:05 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: DE LA VEGA ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197607356
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/09/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80087(g)

Buildings and Grounds 80087(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above due to LPAs' observation of sharps located on the dishrack and unlocked in a drawer. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/11/2022
	Plan of Correction
1 2 3 4	Administrator agreed to train all staff on having sharps inaccessible to residents at all times. Administrator agreed to purchase a locked tool box to keep sharps inside. Staff sign-in sheet and training materials shall be e-mailed to LPA by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Nichelle Gillyard

LICENSING EVALUATOR NAME:

Joscelyn Martinez

LICENSING EVALUATOR SIGNATURE:

DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

LIC809 (FAS) - (06/04)

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