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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608617
Report Date: 11/20/2023
Date Signed: 11/20/2023 12:12:09 PM

Document Has Been Signed on 11/20/2023 12:12 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: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: 3DATE:
11/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Ceclia CambaTIME COMPLETED:
12:20 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted an unannounced visit for an annual required inspection. LPA met with Administrator Ceclia Camba and informed her the reason of the visit. LPA was allowed to enter and temperature was taken and LPA signed it. LPA observed a hand-sanitizing station and COVID supplies at the front door. There were (3) clients present, and (3) staff were working during the visit. The total census is (6); the remaining clients were in day program. LPA observed licensing required signs, as well as COVID signs posted throughout the facility.
The physical plant tour consisted of: Smoke and Carbon Monoxide detectors tested and function properly. Fire extinguisher observed full charged; first aid kit completed. Kitchen: The kitchen was clean and the appliances had functional fixtures. There was a (2) day supply of perishable and seven (7) day non-perishable. Food was properly stored and labeled. Knives are stored inaccessible in locked cabinet. Cleaning supplies locked cabinet in the garage area. Bedrooms: There are four (4) bedrooms designated for residents' use and two (2) staff rooms. All bedrooms were clean, properly furnished and have sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.8. Common Areas: The common areas (living/dining) appeared clean and were properly furnished. Surrounding Grounds: Entry/exits were free of obstruction. Laundry area is near the kitchen area.
Client and Staff Records: Client files included medical assessments, quarterly appraisals; Individual Program Plan, admission agreements, and all other required forms. P&I money was documented and recorded by staff with purchases and credits for each client. Staff - Staff files included current first aid and CPR certifications as well as training and medication training documentation. Medications: Physician orders for medications and centrally stored medication logs observed. Medications and logs are consistent. Medications appear to be given as prescribed. All staff and clients are vaccinated, including booster shots.

Exit Interview Conducted / A Copy of the Report Issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 11/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/20/2023
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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