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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608617
Report Date: 06/17/2022
Date Signed: 06/18/2022 08:13:55 AM

Document Has Been Signed on 06/18/2022 08:13 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:BLUE RIDGE HOME CARE #3FACILITY NUMBER:
197608617
ADMINISTRATOR:CECILIA CAMBAFACILITY TYPE:
735
ADDRESS:16961 CALAHAN STREETTELEPHONE:
(818) 993-3529
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 6DATE:
06/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:30 PM
MET WITH:Rowena Cruz - AdministratorTIME COMPLETED:
06:30 PM
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A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Rowena Cruz, Administrator and purpose of the visit explained. LPA observed that the six (6) residents were at the facility during visit.

A tour of the physical plant was conducted at 3:45 PM and the following was noted:

The front main door is the only entrance being utilized at the facility. There is a sign on the front door that everyone entering at the facility must be screened. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask.

The facility had submitted and approved Mitigation and Infection Control Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the garage.

Facility has four (4) client bedrooms and has two (2) bathrooms. Additional two (2) bedrooms are designated for staff use. There is no body water in the facility.

(continued to LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/17/2022
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: BLUE RIDGE HOME CARE #3
FACILITY NUMBER: 197608617
VISIT DATE: 06/17/2022
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(continued from LIC 809)

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels.
Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature was measured at 115.7°F and within the required range.
Physical plant was checked for cleanliness and condition. Facility was in good repair and observed to be clean and free of clutter during today's visit.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition.
Kitchen area was observed to be clean and sanitary. Laundry area is located adjacent to the kitchen. Laundry detergents and other cleaning agents and toxins are kept locked in the cabinet in the laundry area. Knives and sharps were also kept in the locked cabinet in the laundry area.
Food. The facility is observed to have sufficient food supply for the clients both perishable and non-perishable.
Temperature of facility wall thermostat was set at 76°F and observed to be within the required range.
Fire extinguisher - There is a fire extinguisher located in the kitchen. Extinguisher was observed to be operable and last bought on 06/115/22. Smoke alarms were hardwired and inter connected, tested and observed to be operational. There is a carbon monoxide installed at the facility.

Garage is attached to the house but has no access from the inside. Garage is also used as PPE supplies, frozen food and other supplies storage.

Medication was observed to be inaccessible and stored in a secured medication cabinet. There is a complete First Aid kit inside the medication cabinet.



There was no immediate health and safety hazard observed during the day of inspection. Exit interview conducted and a copy of this report was given.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2022
LIC809 (FAS) - (06/04)
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