197608215-4-27-2022-31-AS-TSMH-CDVNK3-20220427103112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608215
Report Date: 04/21/2022
Date Signed: 04/27/2022 10:31:36 AM

Document Has Been Signed on 04/27/2022 10:31 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PACOIMA ADC		FACILITY NUMBER:	197608215
ADMINISTRATOR:	VERJINE EGIAN		FACILITY TYPE:	775
ADDRESS:	13117 VAN NUYS BLVD		TELEPHONE:	(818) 434-0004
CITY:	PACOIMA	STATE: CA	ZIP CODE:	91331
CAPACITY: 90		CENSUS: 40	DATE:	04/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	VERJINE EGIAN		TIME COMPLETED:	02:40 PM

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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced One (1) Year Required Infection Control visit to this facility. LPA was greeted by activity coordinator/caregiver Mireya Delgadillo who stated the administrator would be arriving within 15-20 minutes. LPA disclosed to staff the purpose of the visit.

LPA conducted a tour of the physical plant at 11:15 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

There are hand sanitizing stations all over the facility including signs to wear a mask and other Covid 19 prevention protocol signs were posted near the entry door.

The facility consists of one big room with tables, chairs, sofas, and a kitchen with cabinets. There were games and a television for clients to use. The administrator office is located in the front of the facility to left of the front reception desk. An office for the assistant administrator is located to the right of the reception desk.

A quiet/library room for clients to use is located next to the assistant administrator office. LPA viewed storage space for client and staff belongings. There is a locked cabinet available for client and staff files. There is a copy machine to be used for clients and staff.

There are two (2) bathrooms: one for men and one for women located towards the back of the facility on the right side of the hallway. LPA observed all bathrooms to have grab bars, paper towels and trash cans. The hot water measured to 105.0-120.0.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PACOIMA ADC	FACILITY NUMBER: 197608215
	VISIT DATE: 04/21/2022

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(Cont from 809)

A fitness room with two (2) stationary bicycles, two (2) treadmills, three (3) arm cycles, and steps is located on the left side of the facility. There is a computer room at the end of the hallway on the right near the rear exit. The facility areas were observed to be clean and properly furnished.

Clients medication to be stored in locked cabinet in assistant administrator’s office. The first aid kit located in administrator’s office. The three (3) fire extinguishers observed with current receipt attached. Smoke alarm and carbon monoxide detector in kitchen present and function properly. Facility maintains a comfortable temperature of 70.0 F.

A camera system in place, that has views of outside, main area, exercise room. The camera system control is located in the administrator's office. There is an outside activity space in back.

No Deficiencies cited. Exit interview conducted and report printed.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 04/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/21/2022

LIC809 (FAS) - (06/04)

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