197607891-5-28-2024-31-AS-NRED-D5PQ5G-20240528115156

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607891
Report Date: 05/28/2024
Date Signed: 05/28/2024 11:55:53 AM

Document Has Been Signed on 05/28/2024 11:55 AM - 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:	CNS MARTHA		FACILITY NUMBER:	197607891
ADMINISTRATOR/ DIRECTOR:	MARC SAINT CLAIR		FACILITY TYPE:	735
ADDRESS:	19443 MARTHA STREET		TELEPHONE:	(818) 342-9443
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY: 6		CENSUS: 5	DATE:	05/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	08:30 AM
MET WITH:	Marc Saint Clair		TIME VISIT/ INSPECTION COMPLETED:	11:50 AM

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At 8:30 a.m. on 05/28/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the administrator and disclosed the reason for the visit.

LPA and administrator toured the facility inside and out at 9:15 a.m.

The facility was last visited on 01/23/24 for a case management visit. It is a single story building with five (05) bedrooms, five (05) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which four (04) may be bedridden. Surveillance cameras were observed in common areas and on the facility perimeter. The front access is gated and requires a PIN code for entry. The front yard was well maintained. A centralized auditory alarm system was operational. Fire sprinklers were located throughout the facility.

At the main entrance, LPA observed postings for personal rights and the facility license. A sign-in sheet and hand sanitizer were available. Additional postings were observed inside for emergency contacts, emergency disaster plan, confidential complaint contacts, and administrator certificates. At approximately 9:30 a.m. LPA observed a fully charged fire extinguisher at the main entrance. It was last inspected on 12/11/23. Two other extinguishers were observed near the garage and in the kitchen. At approximately 9:45 a.m., smoke and carbon monoxide detectors were tested and operational.

The facility has five (05) bedrooms. Four (04) bedrooms are private, and Bedroom #1 is a shared room. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #3 had a sign posted for “No smoking – Oxygen in use”.

The facility has five (05) bathrooms, two (02) of which were private. All bathrooms contained liquid soap, paper towels, trash can with a tight-fitting lid, grab bars near the toilet and shower, and a non-skid mat or non-skid surface in the shower. At approximately 10:30 a.m. LPA measured the water temperature in the private bathroom to Bedroom #1 to be 105.5 degrees Fahrenheit.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

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: CNS MARTHA	FACILITY NUMBER: 197607891
	VISIT DATE: 05/28/2024

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LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. Cabinet space and storage racks were equally divided for residents. The stove hood was clean. Appliances were in good condition. A menu for specialized diets was posted. Sharps, cleaning solutions, and medications were locked in a pantry near the kitchen as well as underneath the sink. Two (02) washing machines and two (02) dryers were located adjacent to the kitchen.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:45 a.m. LPA measured the room temperature to be 73.4 degrees Fahrenheit. The living room contained board games, reading material, television, and furniture in good repair. The garage was locked and stored extra resident supplies. LPA observed multiple covered patio areas in the rear of the facility. The patio contained furniture in good condition, exercise equipment, and a maintained back yard area. A separated office area was locked and stored confidential files. All emergency exit paths were free from obstructions. Evacuation routes were posted. The facility uses three (03) wheelchair-accessible vans. All three (03) vehicles were in use during today’s visit and unavailable for inspection.

No immediate health and safety risks were observed during this visit.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC809 (FAS) - (06/04)

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