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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608711
Report Date: 10/16/2024
Date Signed: 10/16/2024 02:25:09 PM


Document Has Been Signed on 10/16/2024 02:25 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:FOOTHILL RETIREMENT CARE HOMEFACILITY NUMBER:
197608711
ADMINISTRATOR:JECERY NINONUEVOFACILITY TYPE:
740
ADDRESS:6720 SAINT ESTEBAN STREETTELEPHONE:
(818) 353-3350
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY:72CENSUS: 34DATE:
10/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:23 AM
MET WITH:David Monroy - VP OperationsTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Gary Tan initially met with Interim Administrator Magdalena Cabrera for a One (1) Year Required visit for this facility. Interim Administrator Magdalena called the Vice President for Operation David Monroy and explained the reason for the visit.

A tour of the physical plant was conducted at 9:42 AM and the following was noted:

There is only one entrance being utilized at the facility, the front main entrance door. There are required poster posted at the main door. Screening area is located immediately upon entrance with hand sanitizer. There is also a sign in sheet, hand sanitizer, gloves and masks available. The facility had submitted and approved Mitigation and Infection plan.

There are hand sanitizing stations all over the facility. There are signs to wear a mask and other Covid 19 prevention protocol signs were posted in doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in common bathrooms and all over the common areas of the facility. The facility have designated visitors' area at the back yard. The facility has sufficient stock of PPE in the storage.

The facility has three (3) separate buildings on the same property. First property is the main building consisting of living room, dining room, kitchen and offices. Second building is called the Cottages which consists of six (6) individual units and the third building is the memory care unit (MCU) which has delayed egress installed on all exit doors, MCU consists of dining room, medication room and beauty shop. All indoor and outdoor passageways/exits were free of obstruction. There is no body of water in the facility. The facility maintains a comfortable temperature at 74°F. The facility is fire cleared for seventy two (72) non-ambulatory residents, Forty (40) of which may be bedridden. Approved for delayed egress and hospice waiver for ten (10) residents.

(continued on LIC 809-C)
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/16/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FOOTHILL RETIREMENT CARE HOME
FACILITY NUMBER: 197608711
VISIT DATE: 10/16/2024
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(continued from LIC 9099)

Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient supply of perishable and non-perishable food and properly stored at the facility. Knives, cleaning agents, and other potentially hazardous items were locked and inaccessible.
Bedrooms: The resident bedrooms were properly furnished with one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.
Bathrooms: LPA observed all bathrooms to be clean, properly supplied and equipped with functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. There is a common shower rooms in the facility observed to be clean and in good repair. Hot water was measured in random bathroom at the range of 109.5°F to 119.7°F and observed to be within the required range.
Common Areas: These includes the living room, dining room and outdoor areas. Facility common areas appeared to be clean and appropriately furnished at the time of this visit, no accessible hazards were observed. Surrounding Grounds (Outdoors): The property has a covered patio area behind the main building with chairs and additional umbrella covered tables. There is also a covered picnic area in the back of the building. The facility's smoke alarms are hard wired and tested regularly every month. Fire inspection was last done on 03/27/24. The facility is also equipped with sprinkler system which was last tested on 03/27/24. Fire extinguishers are located all throughout the facility and were last serviced on 06/03/24. Fire drill was last conducted on 09/28/24.

Medications were observed to be stored in designated Medication room. The Medication room was observed to be locked at the time of visit. There is a complete set of first aid kit in the Medication room.
Resident/Staff File Review: LPA reviewed records of four (4) random residents and five (5) staff. Resident and staff records appeared to be complete and updated.
Laundry room located in a separate structure near the garage and observed to be locked during visit.

Exit interview conducted. Copy of this report issued,
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 10/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2024
LIC809 (FAS) - (06/04)
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