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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607356
Report Date: 12/04/2023
Date Signed: 12/05/2023 09:53:00 AM

Document Has Been Signed on 12/05/2023 09:53 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:DE LA VEGA ADULT RESIDENTIAL FACILITYFACILITY NUMBER:
197607356
ADMINISTRATOR:EILEEN TAGDULANGFACILITY TYPE:
735
ADDRESS:17521 TUBA STREETTELEPHONE:
(818) 366-3282
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 5DATE:
12/04/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:EILEEN TAGDULANG- AdministratorTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with Administrator Eileen Tagdulang and explained the reason for the visit. At approximately 11:15 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the dining area. The smoke alarms are interconnected and battery-operated. There is a carbon monoxide detector that functions properly installed in the hallway between clients rooms. The fire extinguisher is located in the kitchen, the purchase date 4/16/23. This is a seven (7) bedroom and three (3) bathroom single story Adult Residential Home. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked box in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Laundry room is located near the kitchen. Appliances observed to be in good repair. All detergent and cleaning supplies are locked in the pantry room. Bedrooms: There were five (5) bedrooms designated for clients' use. Two (2) bedrooms designated for staff. All five bedrooms, in use by clients, were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for clients' use. One (1) bathroom designated for staff. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathrooms sink at 105.2 and 106.4 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. There is a swimming pool that is fenced all around it's parameters. The fence was at least five foot high with a gate, that is also five foot high. Gate was observed locked, making it inaccessible to clients to enter. Resident Files: LPA conducted a file review of Client records to insure compliance of licensing forms. Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.Medications: Medication and Medication Records were review for proper documentation.Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 12/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/04/2023
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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