197608611-11-1-2022-31-AS-TSMH-CKRT6D-20221101142658

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608611
Report Date: 11/01/2022
Date Signed: 11/01/2022 02:27:02 PM

Document Has Been Signed on 11/01/2022 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ESTAR RESIDENTIAL CARE		FACILITY NUMBER:	197608611
ADMINISTRATOR:	ARNALDO A. HUKOM		FACILITY TYPE:	740
ADDRESS:	8559 BOTHWELL ROAD		TELEPHONE:	(818) 727-1953
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 4	DATE:	11/01/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:35 AM
MET WITH:	Arnaldo Hukom		TIME COMPLETED:	02:30 PM

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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced One (1) Year Required Infection Control visit for this facility at 10:35 am. On entry care staff disclosed will contact the administrator. The administrator was called and would return shortly. LPA explained to care staff the reason for this visit. Administrators arrived at the facility at approximately 11:25 am and LPA disclosed the purpose of the visit.

LPA conducted a tour of the physical plant at 10:50 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 on entry door. The facility has a total of six (6) bedrooms and three (3) bathrooms. The rooms are designated as follows: Five (5) rooms for residents and one (1) room for staff. The bedrooms had adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets for residents’ comfort and safety.

There are two (2) bathrooms available for resident use. Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the two (2) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 121.7- and 123.5-degrees Fahrenheit. Facility maintains a comfortable temperature for residents.

Common areas were observed for the ability to safely serve the needs of residents. These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed furnished appropriately. LPA observed a sufficient supply of linens and toiletries in two (2) hallway closets.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the four (4) residents currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats and frozen vegetables. Sharp objects are stored in a locked drawer. The resident’s medications and first aid kit are locked in dining area cabinets next to kitchen entry.

(Cont to 809C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

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: ESTAR RESIDENTIAL CARE	FACILITY NUMBER: 197608611
	VISIT DATE: 11/01/2022

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(Cont from 809)

Laundry room appliances observed to be functional. Toxins locked in laundry room and stored on shelves. Laundry observed to be locked and inaccessible to residents. Smoke alarms and carbon monoxide detectors were present and function properly. There are two (2) fire extinguishers one (1) located in hallway near dining room and one (1) located in locked laundry room observed to be charged. An adequate supply of PPE’s is stored in cabinet in living room.

There is a large patio table and chairs shaded by a large umbrella for clients use in the backyard. Patio furniture observed to be in good repair with adequate seating for the residents.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection. There are no deficiencies to report.

Exit interview conducted and copy of report given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 11/01/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2022

LIC809 (FAS) - (06/04)

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