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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608318
Report Date: 05/20/2024
Date Signed: 05/20/2024 12:09:25 PM


Document Has Been Signed on 05/20/2024 12:09 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:CEDARCREEK VILLAFACILITY NUMBER:
197608318
ADMINISTRATOR:RICHARD K. GORDONFACILITY TYPE:
740
ADDRESS:20237 CEDARCREEKTELEPHONE:
(818) 269-2230
CITY:SANTA CLARITASTATE: CAZIP CODE:
91351
CAPACITY:6CENSUS: 4DATE:
05/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Angel Gomez - House ManagerTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an annual inspection. LPA was greeted by house manager Angel Gomez, who allowed LPA to enter. LPA observed (2) additional staff on duty. Everyone was explained the reason of the visit, and the Administrator was contacted and informed as well. Licensing and COVID postings visibly seen throughout the facility. A physical plant tour was conducted inside and outside with house manager Angel. The following was observed: At the front entrance, LPA observed a screening area, that included a sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over.

Common areas: Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. There are (02) bathrooms, that had grab bars, and non-skid mats. Hot water measured at 114.8 degrees Fahrenheit. The garage is used for office, storage and laundry. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage. Kitchen: Food Service/Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. There are (2) additional refrigerators located in the garage, stocked with food. Bedrooms: The facility has (4) bedrooms residents; with (1) room for staff. All bedrooms were properly furnished and supplied with appropriate bedding and linens. (2) rooms are shared and (2) private. There were sufficient linens observed and available. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. There are no swimming pools or other bodies of water. All exit doors have locks; all were operating. Fire extinguisher fully charged.First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors were tested and operating properly. Record review: A complete record review of staff and residents was conducted; all required documents were in file. Medication reviewed; no errors observed.Exit interview and copy of report provided.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 05/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/20/2024
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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