197608114-4-19-2023-31-AS-MAGN-CR2T6C-20230419142654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608114
Report Date: 04/19/2023
Date Signed: 04/19/2023 02:27:46 PM

Document Has Been Signed on 04/19/2023 02:27 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
N LA & CEN COA AC/SC, 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: 5	DATE:	04/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:50 PM
MET WITH:	Bruce Partridge- Administrator		TIME COMPLETED:	03:00 PM

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At 1:15pm Licensing Program Analysts (LPAs), Angela Panushkina and Mariana Agban conducted an unannounced annual inspection at the facility mentioned above. LPAs were greeted by the staff, Ronwaldo Diaz who granted access to the facility. Administrator arrived shortly after and LPAs explained the reason for the visit.

At 1:25 pm, LPAs conducted a tour of the facility and the following was observed:

Infection control: The facility had submitted and approved Mitigation Plan and Infection Control Plan. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPAs observed all trash can throughout the facility have fitted lids.

Kitchen: At approximately, 01:40 pm LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. There is a fire extinguisher in the kitchen and it was last purchased on 04/06/2023

Medications: At approximately, 2:00 pm LPAs observed medications are centrally stored and locked in the cabinet in a caregivers room and inaccessible to residents in care. LPAs also observed a First Aid Kit complete with the required items as per Title 22 Regulations.

Bedrooms: There are five (5) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. One room is vacant. Facility has awake staff. Auditory alarms were tested and observed to be operational. Continue on LIC9099-C

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PORTER RANCH ALOHA III	FACILITY NUMBER: 197608114
	VISIT DATE: 04/19/2023

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Bathrooms: At 2:10 pm LPAs observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 112.23°F. LPAs observed appropriate grab bar and non-skid mat. LPAs observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination.

Common Areas: The facility maintains a comfortable temperature at 74°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

Outside areas: At approximately, 2:25 pm LPAs toured the outside area of the facility. Facility has a swimming pool that is fenced all around with a gate and kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around its parameters. LPAs also observed a clean covered patio and backyard furniture to accommodate the five (5) residents. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents.

The garage: Laundry area is located by the attached garage and kept locked and inaccessible to residents. Extra PPE supplies and food storage was also observed.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:55am they were tested and observed to be operational.

Between 2:30 pm to 3:00pm, LPAs reviewed records of five (5) residents and two (2) staff. Resident and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 04/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/19/2023

LIC809 (FAS) - (06/04)

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