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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607632
Report Date: 05/04/2023
Date Signed: 05/04/2023 03:06:38 PM

Document Has Been Signed on 05/04/2023 03:06 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., 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:
05/04/2023
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Victoria Torres TIME COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted a Case Management Visit (CM) visit to insure facility compliance. The Department received notification from the Local Fire Department had some concerns regarding fire clearance. LPAs were joined by inspectors from the Los Angeles Fire Department (LAFD) Lindsey Pellegrini and Chase Mendenhall, fire prevention. Today's visit consisted of an inspection of the physical plant to insure the facility compliance, inspect passageways and exits to insure it is free of obstruction. Facility smoke alarms are interconnected. The fire extinguisher is located in the living room. Charge date is February 15, 2023.

Pursuant to title 22, the following deficiency was observed. Citation issued on the 809D. Licensee was also given advisory notice to insure compliance.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 05/04/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/04/2023
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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Document Has Been Signed on 05/04/2023 03:06 PM - It Cannot Be Edited


Created By: Michael Cava On 05/04/2023 at 11:56 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VICKY RESIDENTIAL HOME CARE
FACILITY NUMBER: 197607632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/04/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/04/2023
Section Cited
CCR
87887(c)

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Buildings and Grounds: All outdoor and indoor passageways, stairways, inclines, ramps, open porches and other areas of potential hazard shall be kept free of obstruction. This requirement has not been met as indicated by observation during a physical plant inspection. LPA and the
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During the visit, staff removed the latch. No further corrections required at this time.
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Fire Inspectors observed a small latch that can be used as an additional lock to the front door. This would be an immediate health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Michael Cava
LICENSING EVALUATOR SIGNATURE:
DATE: 05/04/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/04/2023


LIC809 (FAS) - (06/04)
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