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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607632
Report Date: 08/13/2023
Date Signed: 08/13/2023 03:40:57 PM

Document Has Been Signed on 08/13/2023 03:40 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:VICKY RESIDENTIAL HOME CAREFACILITY NUMBER:
197607632
ADMINISTRATOR:VICTORIA C. TORRESFACILITY TYPE:
735
ADDRESS:16521 MCKEEVER STREETTELEPHONE:
(818) 360-2174
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 4DATE:
08/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:12 PM
MET WITH:Ronald Barit - AdministratorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Gary Tan conducted an unannounced Required One (1) year visit to this facility. LPA met with back up Administrator Ronald Barit and explained the purpose of the visit. This is a North Los Angeles Regional center vendored facility Level II.

At 12:20 PM, LPA conducted a physical plant tour assessment and the following was noted:

The main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear mask and must be screened. 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 on the walls. 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 backyard. The facility has sufficient stock of PPE in the storage room.

Facility has four (4) private client bedrooms. There is one (1) additional bedroom designated for the staff and one (1) room designated as an office. The facility has two (2) bathrooms. There is no body of water in the facility.

Bedrooms were toured and observed to be clean and have appropriate lighting and furniture.
Bathrooms were observed to be clean and have necessary supplies. Hot water temperature measured at
a range of 105.6°F to 108.8°F. Linen closet was also inspected and observed to have sufficient stock of clean linen and towels. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/13/2023
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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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: VICKY RESIDENTIAL HOME CARE
FACILITY NUMBER: 197607632
VISIT DATE: 08/13/2023
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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 clean and in good repair.
Kitchen area was observed to be clean and sanitary. All disinfectants, cleaning solutions and poisons are locked in the cabinet below the kitchen sink.
Food. The facility was observed to have sufficient food supply for clients. Temperature of facility wall thermostat was set at 75.0°F to and observed to be within the required range.
Fire extinguisher was observed in the living room wall. Extinguisher was observed to be operable and current, last inspection was done on 01/15/23.
Garage is detached from home and being used as a storage and observed to be locked and inaccessible to residents. Laundry area is located in the backyard immediately after exit. Laundry soap and other toxins are kept in a locked cabinet in the laundry area.
Medication were observed to be locked, inaccessible and stored in the kitchen cabinet. Medication records and procedures reviewed with staff. First aid kit was located in the medication cabinet was observed to be complete.
Client records were reviewed for current IPP’s/ or Needs and Service plans. physician report, admission agreements and P&I funds. Client records appeared to be complete and updated.
Staff records were also reviewed. Staff present has criminal record clearances and associated to this facility. Current training and first aid/CPR observed for staff on duty. Administrator's certificate observed to be current.

Disaster drill was last conducted on 06/04/23. Required posting observed in facility (including complaint hot line poster).

There is no health and safety hazard observed during todays inspection.

Exit interview conducted. Copy of this report provided.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/13/2023
LIC809 (FAS) - (06/04)
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