197608807-8-21-2024-29-AS-ABAN-D8CR7N-20240821124638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608807
Report Date: 08/21/2024
Date Signed: 08/21/2024 12:47:04 PM

Document Has Been Signed on 08/21/2024 12:47 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CNS DOLOROSA		FACILITY NUMBER:	197608807
ADMINISTRATOR/ DIRECTOR:	MARC SAINT CLAIR		FACILITY TYPE:	735
ADDRESS:	22341 DOLOROSA STREET		TELEPHONE:	(818) 574-5312
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 5	DATE:	08/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:45 AM
MET WITH:	Marc Saint Clair		TIME VISIT/ INSPECTION COMPLETED:	01:00 PM

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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 09:45AM. LPA Barutyan called Administrator Marc Saint Clair who arrived at 10:35AM and explained the reason for the visit.

Beginning at 10:37AM, the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers are fully charged and were last serviced 12/11/2023. Hardwired smoke and carbon monoxide detectors and fire doors were tested at 12:15PM and all were functional at the time of the visit. LPA observed exit alarms by all doors which were functional and operating.

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 2 (two) days perishable and 7 (seven) days non-perishable food.

BEDROOMS: There are five (5) bedrooms of which four (4) are designated as private rooms and 1 (one) is designated as a shared room. Three (3) rooms have exits to the exterior. All bedrooms were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: There are four (4) restrooms, two (2) are attached to client rooms and two (2) are shared use. LPA observed bathrooms to be clean, sanitary and in operating condition with grab bars and non-skid surfaces. Water temperatures were measured in all four (4) bathrooms between 109.3 F - 110.1 degrees Fahrenheit between 10:51AM-10:58AM.

Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CNS DOLOROSA	FACILITY NUMBER: 197608807
	VISIT DATE: 08/21/2024

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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. LPA observed required postings throughout the common space. No bodies of water were noted in the backyard. LPA observed a fireplace in the living room that was appropriately screened. Medications are locked inaccessible in the medication designated area in between the kitchen and living room.

GARAGE AND GROUNDS: The garage is not accessible from the house and is used as a storage room. Cleaning solutions and hazardous chemicals are stored locked and inaccessible. There are additional supplies and emergency food and water. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs where clients can sit.

RECORD REVIEW: Beginning at 11:14AM, LPA reviewed four (4) staff and five (5) client files for documents including but not limited to: client Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All five (5) client files and four (4) staff records reviewed were in compliance with regulation at the time of the visit.

MEDICATION REVIEW: Beginning at 12:17PM, LPA reviewed medications for two (2) clients. All medications reviewed were stored and documented per regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 07/25/2024.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 08/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/21/2024

LIC809 (FAS) - (06/04)

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