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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608410
Report Date: 01/18/2022
Date Signed: 01/18/2022 03:50:32 PM

Document Has Been Signed on 01/18/2022 03:50 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:LAURELGROVE MANORFACILITY NUMBER:
197608410
ADMINISTRATOR:SELVA W BANOSFACILITY TYPE:
735
ADDRESS:7841 LAURELGROVE AVENUETELEPHONE:
(818) 255-4733
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 4CENSUS: 3DATE:
01/18/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:00 PM
MET WITH:Selva BanosTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection at 2:00p.m. This annual inspection had an emphasis on infection control practices and procedures. LPA Urena met with administrator Selva Banos at 2:25 p.m., introduced herself, and explained the reason for the visit.

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. The facility has a sufficient supply of perishable and non-perishable food. The dining room furniture was observed to be in good condition. The LPA observed a fire extinguisher in the kitchen area to be fully charged and operational. The LPA observed sharp objects and toxins to be locked away and inaccessible from residents.

BEDROOMS: The LPA observed three residents’ bedrooms, which were furnished appropriately with clean linens, furnishings and sufficient lighting. Bedrooms #1,2, and 3, were occupied with one resident per bedroom. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms are sufficiently stocked with hand liquid soap and paper towels.

COMMON SPACES: In the common areas, walls, flooring and furniture were checked for cleanliness and were in good condition. Required postings were observed in the entryway.

OUTDOOR AREA: The LPA observed the backyard to be free of clutter and debris, and observed outdoor patio/furniture for residents’ use.


Continues on LIC 809C...
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/18/2022
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAURELGROVE MANOR
FACILITY NUMBER: 197608410
VISIT DATE: 01/18/2022
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Record Review: At approximately 3:30 p.m. LPA conducted a resident and staff file review. LPA also checked medication and medication documentation.

LPA Urena observed 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 facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview was conducted. The report was reviewed with the administrator, and signatures were obtained. A copy of the report was provided via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 01/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/18/2022
LIC809 (FAS) - (06/04)
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