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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608807
Report Date: 07/06/2022
Date Signed: 07/06/2022 12:28:59 PM

Document Has Been Signed on 07/06/2022 12:28 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:CNS DOLOROSAFACILITY NUMBER:
197608807
ADMINISTRATOR:MARC SAINT CLAIRFACILITY TYPE:
735
ADDRESS:22341 DOLOROSA STREETTELEPHONE:
(818) 574-5312
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
07/06/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Marc Saint ClairTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:15 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Marc Saint Clair and explained the reason for the visit.

The LPA, along with the administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives are stored in a locked cabinet in the kitchen and hallway closet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The LPA observed four single-room client bedrooms and one shared room which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: The four restrooms are clean, sanitary and in operating condition with grab bars and non-skid surfaces. The LPA observed appropriate hand-washing signs in the restrooms. Water temperatures measured between 105.0 degrees Fahrenheit and 105.4 degrees Fahrenheit between 11:21 a.m. and 11:29 a.m.

COMMON SPACES: Walls and flooring were checked for cleanliness and good condition. The washer and dryer are located in a laundry room in the hallway all laundry supplies were appropriately locked at the time of the visit. Passageways were clean and clear of obstructions. No bodies of water were noted in the backyard. The LPA observed all the required postings that promoted cough etiquette, signs and symptoms of COVID-19, and appropriate hand hygiene. Medications are locked inaccessible in the medication designated area in between the kitchen and living room. .

Continued on LIC 809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/06/2022
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CNS DOLOROSA
FACILITY NUMBER: 197608807
VISIT DATE: 07/06/2022
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INFECTION CONTROL: The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. The facility can designate a single isolation room if the facility has a confirmed case of COVID-19. The Administrator is up to date regarding policies around vaccinations, visitation, and the required updates needed for the facility's Plan of Operation. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited at this time. Exit interview conducted. Signatures obtained.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:

DATE: 07/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/06/2022
LIC809 (FAS) - (06/04)
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