197608617-7-11-2024-31-AS-LNCA-D73M62-20240711091914

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608617
Report Date: 07/09/2024
Date Signed: 07/11/2024 09:19:32 AM

Document Has Been Signed on 07/11/2024 09:19 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BLUE RIDGE HOME CARE #3		FACILITY NUMBER:	197608617
ADMINISTRATOR/ DIRECTOR:	CECILIA CAMBA		FACILITY TYPE:	735
ADDRESS:	16961 CALAHAN STREET		TELEPHONE:	(818) 993-3529
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 6	DATE:	07/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:18 PM
MET WITH:	Karla Plata- Asst. Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with Cecilia Camba who is the administrator and explained the reason for the visit. Approximately, around 12:30 PM assistant administrator Karla Plata arrived and was explained for the reason of the visit. At 12:35 PM, with the assistance of assistant administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 5/6/2024. During the visit the facility is at 74 degrees Fahrenheit. The facility is fire cleared for six (06) ambulatory. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet in the laundry room. Properly labeled medications were locked in the staff dining area cabinets in between kitchen and laundry station. Bedrooms: There were six (6) bedrooms designated for residents' and staff use. Four of the that bedrooms are in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Room #1 and #4 are properly furnished and occupied by only one (1) resident. Room #2 and #3 are shared room. There are two (2) staff bedroom in the facility that is located at the end of the hallway beside bathroom #2 and another staff room located by the living room, staff bedrooms are locked with no medication in sight. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE RIDGE HOME CARE #3	FACILITY NUMBER: 197608617
	VISIT DATE: 07/09/2024

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Bathrooms: There are two (2) bathrooms designated for residents' and staff use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105.7 degrees Fahrenheit for bathroom #1 located in the hallway beside room #1. Bathroom #2 measured 105.4 degrees Fahrenheit that is located beside room #2. Cleaning supplies are being stored in a locked cabinet in the laundry room. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. Office space is in the living room area. Fireplace is closed, block-off and non-operational. The auditory alarms on all exit doors were on and functional at the time of the visit. Residents dining table fits enough for six (6).

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area and detergents are located by the laundry room beside the kitchen that are kept lock and secured. The facility does not have a swimming pool or body of water. The garage is detached and is used for storage for incontinence supplies and staff refrigerator.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records (MMR) were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit interview conducted and a copy of the report issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 07/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2024

LIC809 (FAS) - (06/04)

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