197608114-4-4-2022-31-AS-JMAZ-CD6SUR-20220404141133

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608114
Report Date: 04/04/2022
Date Signed: 04/04/2022 02:12:13 PM

Document Has Been Signed on 04/04/2022 02:12 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:	PORTER RANCH ALOHA III		FACILITY NUMBER:	197608114
ADMINISTRATOR:	BRUCE PARTRIDGE		FACILITY TYPE:	740
ADDRESS:	19911 VINTAGE STREET		TELEPHONE:	(818) 626-8989
CITY:	CHATSWORTH	STATE: CA	ZIP CODE:	91311
CAPACITY:	6	CENSUS: 6	DATE:	04/04/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Bruce Partridge		TIME COMPLETED:	02:20 PM

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25

Licensing Program Analyst (LPA) Joscelyn Martinez conducted an unannounced annual inspection. Upon arrival LPA met with staff and later met with Administrator Bruce Partridge. The purpose of the visit was explained.

At 1:00 p.m. LPA conducted a physical tour of the facility. Infection Control: Covid-19 infection control signage were observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, staff took LPA’s temperature and was asked to sign-in the visitor’s log. Facility has sufficient PPE supplies for more than 30 days. Food Inspection: At 1:21 p.m. LPA Martinez observed there was not sufficient stock of one-week non-perishable foods and two-day perishable foods. Sharps and medications are centrally stored in a locked area. Garbage can has a tight-fitting lid in the kitchen. Smoke detectors/carbon monoxide are located throughout the facility. Smoke detectors and carbon monoxide detectors were tested at 1:38 p.m. and appear to be functional. Fire extinguisher has a purchase date of 04/27/2021. Common Areas: All common areas were observed to be clean and properly furnished. Facility maintains a comfortable temperature of 71.0 F. Residents Rooms: There are six (6) bedrooms all designated for private resident use. All the six (6) bedrooms were toured and appear to be clean and properly furnished. LPA observed additional bedding and linens sufficient for all of the residents. Bathrooms: There are four (4) bathrooms in the facility. LPA observed all bathrooms to have grab bars and non-skid mats. The hot water was tested and measured at 110.4 F.

(Continue on 809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PORTER RANCH ALOHA III	FACILITY NUMBER: 197608114
	VISIT DATE: 04/04/2022

NARRATIVE

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32

Garage: There is a laundry room that leads into the attached garage. The laundry area door remains locked and inaccessible to residents. Garage is used for additional storage. Cleaning supplies are kept inside the garage. Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. The facility has a swimming pool that is locked and inaccessible to residents.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 04/04/2022 02:12 PM - It Cannot Be Edited

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PORTER RANCH ALOHA III	FACILITY NUMBER: 197608114
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 04/04/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87555(b)(26)

Supplies of nonperishable foods for a minimum of one week and perishable foods for a minimum of two days shall be maintained on the premises. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in ensuring there is sufficent food supplies to meet regulation for all residents which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/07/2022
	Plan of Correction
1 2 3 4	Administrator will shop for food and send proof of food purchase to LPA via email. Foods should cover all meal periods and variety shall take into account and special diets.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 04/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/04/2022

LIC809 (FAS) - (06/04)

Page: 3 of 3