197607356-12-10-2024-31-AS-GSAO-DBTSPX-20241210130352

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607356
Report Date: 12/10/2024
Date Signed: 12/10/2024 01:04:21 PM

Document Has Been Signed on 12/10/2024 01:04 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	DE LA VEGA ADULT RESIDENTIAL FACILITY		FACILITY NUMBER:	197607356
ADMINISTRATOR/ DIRECTOR:	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:	12/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:35 AM
MET WITH:	Michael Tagdulang-Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	01:15 PM

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On 12/10/2024 at 9:35 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced, Annual Inspection and met with Assistant Administrator Michael Tagdulang. LPA asked for the census, staff and resident files.

The physical plant was toured inside and out at 10:25 am. This is a level 2 facility with ambulatory residents.

Living Room Area: LPAs observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 77 degrees Fahrenheit with a large television.

Bedrooms: There are seven (7) bedrooms. Five (5) bedrooms are used for residents and two (2) bedrooms are used for staff. The bedrooms have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the Resident’s room. The resident rooms are single, occupied. There is a hallway that divides the rooms and the hallway there is office set-up. The staff rooms were also toured.

Bathrooms: There are three (3) bathrooms that were toured and checked to make sure bathrooms were clean and in good repair. Two (2) bathrooms are used for residents and one (1) bathroom is used for staff. The hot water temperatures were measured within regulations of 116-117 degrees. The showers have non-slip bathmats and grab bars.

The carbon monoxide and the smoke detector were tested, and they were operable, interconnected.

There is no garage. The washer and dryer are located on your right hand side of the kitchen.

809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: DE LA VEGA ADULT RESIDENTIAL FACILITY	FACILITY NUMBER: 197607356
	VISIT DATE: 12/10/2024

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Kitchen Area: LPA inspected the kitchen area. There is one (1) refrigerator which was clean and in good operation with several pantries for canned food. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinets. There is another refrigerator located that can be accessed from the kitchen area.

The knives/sharps are kept in a locked black cabinet that is inaccessible to residents on the kitchen counter.

Medications: The medication is kept on your right hand side of the kitchen locked and inaccessible to the residents. The first/aid kit is kept in the staff's bathroom. There is two (2) first/aid kits.

There is no a signal system in the facility. There are two (2) fire extinguishers fully charged and expires on May-2025. There are located in the kitchen.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has a pool that is fenced and gated inaccessible to the residents. There is also a shed that has storage in it on your right hand side.

Administration: The Liability Insurance was reviewed and expires 08/2025. There are several Covid 19 signs on the wall, hygiene sanitation signs, and the Rights of Individuals with Developmental Disabilities, YES, Emergency Disaster Plan and Facility Grievance Procedure, house rules located against the wall of the dining hall. The staff and resident files were reviewed and documented on the LIC 858 and LIC 859. The annual fee is due by February 2025.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the assistant administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/10/2024

LIC809 (FAS) - (06/04)

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