197607943-12-20-2023-29-AS-SURA-CYPMEP-20231220083300

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607943
Report Date: 12/19/2023
Date Signed: 12/20/2023 08:33:55 AM

Document Has Been Signed on 12/20/2023 08:33 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VIRGINIA CATALINA LLC		FACILITY NUMBER:	197607943
ADMINISTRATOR:	KEVIN SCANLAN		FACILITY TYPE:	735
ADDRESS:	7000 MORSE AVENUE		TELEPHONE:	(818) 394-9878
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 4		CENSUS: 4	DATE:	12/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kevin Scanlan		TIME COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at 10:30 a.m. at the facility unannounced to conduct a required annual visit. The LPA spoke with the Licensee Michelle Feniquitio and explained the reason for the visit. The Administrator Kevin Scanlan arrived shortly thereafter.

The LPA and the administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. Kitchen knives and medications were locked in a top kitchen cabinet. The facility has a sufficient supply of perishable and non-perishable food. The administrator will place thermometers in the refrigerator and freezer to ensure temperatures are kept at designated temperatures.

BEDROOMS: There area four (4) private residents bedrooms. The bedrooms were clean, furnished appropriately with linens, appropriate furnishings, and sufficient lighting. There is a staff bedroom by the laundry area. The room appeared clean, and door was closed at the time of the visit. T

RESTROOMS: Restrooms are clean, sanitary, and in operating condition. Hand washing signs were posted in the bathrooms. Paper towels were available for hand drying.

COMMON SPACES: The living room, and dining area furniture, walls, and flooring were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was fully charged and was last serviced on 06/19/2023 The LPA observed required postings in the office area wall.

Continues on LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VIRGINIA CATALINA LLC	FACILITY NUMBER: 197607943
	VISIT DATE: 12/19/2023

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OUTDOOR/GARAGE: The backyard has outdoor sitting, and shade. The driveway is located on the side of the facility, and has a sliding gate which is kept unlocked. There were no open bodies of water. The garage is attached to the house; it has a door that was locked at the time of the inspection.

LAUNDRY ROOM: The laundry room is adjacent to the kitchen. Laundry supplies were observed to be locked in a top cabinet.

RECORDS: Records review began at 12:15 p.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 1:30 p.m. medications are centrally stored and locked in a top cabinet in the kitchen area ; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has 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.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 12/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2023

LIC809 (FAS) - (06/04)

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