197608410-1-11-2024-29-AS-SURA-CZDN6X-20240111091149

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608410
Report Date: 01/09/2024
Date Signed: 01/11/2024 09:12:35 AM

Document Has Been Signed on 01/11/2024 09:12 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LAURELGROVE MANOR		FACILITY NUMBER:	197608410
ADMINISTRATOR:	SELVA W BANOS		FACILITY TYPE:	735
ADDRESS:	7841 LAURELGROVE AVENUE		TELEPHONE:	(818) 255-4733
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 4		CENSUS: 4	DATE:	01/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Selva Banos		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA Urena spoke with administrator Selva Banos on the phone and explained the reason for the visit. The Administrator arrived shortly thereafter.

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 non-perishable food is located in a locked closet adjacent to the kitchen. 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 to residents.

BEDROOMS: The facility has three residents’ bedrooms, and one staff bedroom. All bedrooms were furnished appropriately with clean linens, furnishings and sufficient lighting. One bedroom has double occupancy, and two bedrooms are single occupancy.

BATHROOMS: The facility has two bathrooms. The bathrooms were 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. Hand washing signs were posted.

Continues LIC 809C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAURELGROVE MANOR	FACILITY NUMBER: 197608410
	VISIT DATE: 01/09/2024

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COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition; walls, flooring and furniture were checked for cleanliness and were in good condition. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was fully charged and was last serviced on 10/23/2023. The LPA observed required postings in the hallway by the kitchen area.

OUTDOOR AREA: The backyard was free of clutter and debris, with outdoor patio/furniture for residents’ use. Laundry area is in a closet outside, which was observed to be locked at the time of the visit.

RECORDS: Records review began at 12:59 p.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 1:57 p.m.; medications are centrally stored and locked in a closet near bedroom #3; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors were observed during the medication review.

INFECTION CONTROL: The facility has 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 LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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