197607518-6-24-2022-29-AS-SURA-CFPSLH-20220624135819

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607518
Report Date: 06/24/2022
Date Signed: 06/24/2022 01:58:53 PM

Document Has Been Signed on 06/24/2022 01:58 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLAGE CARE		FACILITY NUMBER:	197607518
ADMINISTRATOR:	GOHAR GIGI PAPAZIAN		FACILITY TYPE:	740
ADDRESS:	12245 CALIFA STREET		TELEPHONE:	(818) 516-1749
CITY:	VALLEY VILLAGE	STATE: CA	ZIP CODE:	91607
CAPACITY:	6	CENSUS: 5	DATE:	06/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Don Aquino		TIME COMPLETED:	01:00 PM

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On 06/24/2022, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility at 10:30 a.m., unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices and procedures. LPA Urena met with staff. The LPA communicated via phone with the Administrator Gigi Papazian, and explained the reason for the visit.

Infection Control: Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

At 10:42 a.m., LPA Urena and staff conducted a tour of the inside and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Areas: At 10:45 a.m., LPA Urena observed the walls and flooring to be clean and in good condition. At the time of the visit, common seating area, and dining room furniture was observed to be clean and in good condition.

Kitchen: At 10:54 a.m., LPA Urena and staff observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff. The laundry room is equipped with a functioning washer and dryer. Toxic materials are stored in a cabinet in the laundry room. The room was locked at the time of inspection.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE CARE	FACILITY NUMBER: 197607518
	VISIT DATE: 06/24/2022

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Outdoor Space: At 11:10 a.m., LPA Urena and staff observed the Outdoor space. Backyard has a patio outdoor area equipped with outdoor furniture for residents’ use. There were no bodies of water noted. Side gate is unlocked.

Bedrooms: At 11:15 a.m., LPA Urena and staff observed residents’ bedrooms. Four bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition. Extra linens are found stored in the linen cabinet.

Bathrooms: At 11:50 a.m., LPA Urena and staff observed the residents’ restrooms. Restrooms were clean, shower area was in clean condition with grab bars, and a non-skid mat available. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper products in each restroom.

No deficiencies cited during this visit. Exit interview was conducted. The report was reviewed with licensee representative, signatures were obtained, and a copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022

LIC809 (FAS) - (06/04)

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