197608752-10-4-2023-31-AS-MAGN-CWATEV-20231004144034

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608752
Report Date: 10/04/2023
Date Signed: 10/04/2023 02:40:44 PM

Document Has Been Signed on 10/04/2023 02:40 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SENIOR CARE AT NORTHRIDGE INC.		FACILITY NUMBER:	197608752
ADMINISTRATOR:	JAIME MONTERO		FACILITY TYPE:	740
ADDRESS:	19241 CALAHAN STREET		TELEPHONE:	(818) 727-0338
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 6	DATE:	10/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Jaime Montero- Administrator		TIME COMPLETED:	03:00 PM

NARRATIVE

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On 10/04/2023 Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by the Administrator and explained the reason for the visit. A tour of the physical plant was conducted at 9:40 AM.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were stored in locked drawers and cabinets. Medications are locked in the kitchen cabinet. Medications observed to be locked and inaccessible to clients. LPA observed fully stocked first aid kit in the kitchen cabinet.

Bathrooms: There were three (3) bathrooms in the facility. One (1) bathroom in hallway which is the main and one (1) bathrooms in the private bedroom and one (1) designated for staff use. All bathrooms were clean, properly supplied and had functional fixtures. Water temperatures were: 113.2,111.4 degrees Fahrenheit. Bedrooms: There were six (6) bedrooms designated for residents' use. All bedrooms were clean, properly furnished and had sufficient lighting. Common Areas: These included the living room and dining area. The common areas were properly furnished Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was observed to be in need of cleaning. Boxes and miscellaneous items were observed to be piled in the backyard. Temperature: Facility maintains a comfortable temperature of 78 degrees Fahrenheit. Fire extinguisher: is located in the dining room, observed to be fully charged and was purchased on 09/23/2023. Laundry Area-Garage: located in the hallway. Appliances observed to be in good repair. Garage door was locked and thus laundry detergents were inaccessible to residents

Exit interview conducted and deficiencies cited.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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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Document Has Been Signed on 10/04/2023 02:40 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SENIOR CARE AT NORTHRIDGE INC.	FACILITY NUMBER: 197608752
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/04/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87307(d)(2)

This requirement is not met as evidenced by: 87307(d)(2) The following space and safety provisions shall apply to all facilities: The premises shall be maintained in a state of good repair and shall provide a safe and healthful environment..
	Deficient Practice Statement
1 2 3 4	Based on observation , the licensee did not comply with the section cited above. During the tour of the outside, the backyard was observed to have clutter scattered throughout the backyard in different areas. This poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/18/2023
	Plan of Correction
1 2 3 4	Administrator agreed to clean the backyard and submit photos as proof of correction.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana Agban	TELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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