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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607445
Report Date: 05/16/2024
Date Signed: 05/16/2024 09:20:47 PM

Document Has Been Signed on 05/16/2024 09:20 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BLUE EAGLE VILLASFACILITY NUMBER:
197607445
ADMINISTRATOR/
DIRECTOR:		ABRAHAM VALDEZFACILITY TYPE:
735
ADDRESS:1630 N. BRIGHTON STREETTELEPHONE:
(818) 557-7239
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 6DATE:
05/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:31 PM
MET WITH:Alexander Calinog - StaffTIME VISIT/
INSPECTION COMPLETED:
06:47 PM
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An unannounced Required One (1) year visit was conducted on this day by Licensing Program Analyst (LPA) Gary Tan. LPA initially met with staff Alexander Calinog who called the administrator Abraham Valdez and designated Mr. Calinog to sign the report. Purpose of the visit is stated. This is a Lanterman Regional Center vendored facility Level III.

LPA conducted physical plant tour inside and out at 3:40 PM. During the tour, LPA observed that the facility has five (5) bedrooms and two (2) bathrooms. One (1) bedroom is designated for staff use. There is no body of water in the facility.

The front door is the main entrance being utilized at the facility, there is also a door for visitors and deliveries at the kitchen near the garage. There is a sign on the front and side door that everyone entering at the facility must wear mask. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the front yard. The facility has sufficient stock of PPE in the storage

Bedrooms were toured and observed to be clean and appropriately furnished.

Bathrooms were observed to be clean, sanitary and with necessary supplies. Hot water temperature measured at a range of 110.5°F to 118.4°F. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BLUE EAGLE VILLAS
FACILITY NUMBER: 197607445
VISIT DATE: 05/16/2024
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(continued from LIC 809)

Physical plant was checked for cleanliness and condition. Facility was observed to be in good repair and clean during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area is observed to be clean and sanitary. All disinfectants, cleaning solutions and laundry detergents were observed to be locked in the garage.
Food. The facility is observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 74.0°F and observed to be within the required range.
Fire extinguisher was observed to be located by the kitchen. Extinguisher was observed to be operable and last bought on 05/16/24. Fire alarms are hardwired and interconnected and observed to be operational. There is a carbon monoxide detector installed in the facility.
Medications were observed to be locked, inaccessible and stored in the cabinet near the dining room. There was a complete first aid kit located in the supply room inside the staff room closet. Knives and sharps are locked and secured in the kitchen drawer.
Garage is attached to the house and observed to be locked and inaccessible to clients. Laundry room is located adjacent to the living room. Garage is also used as frozen food, emergency supplies and tools and old equipment storage.
Client records. Five (5) client records were reviewed. Clients’ record appeared to be complete and current.
Staff records were also reviewed. Four (4) staff records were reviewed, they all have criminal record clearances and associated to this facility. Current training and first aid observed for staff on duty. Administrator's certificate was observed to be current.

Disaster drill was last conducted on 03/10/24. Required posting observed in facility (complaint hot line poster, personal rights, etc).

There was no health and safety hazard observed during the day of inspection.

Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 05/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2024
LIC809 (FAS) - (06/04)
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