197608838-6-2-2022-31-AS-MRUZ-CEZQRA-20220602122339

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608838
Report Date: 06/02/2022
Date Signed: 06/02/2022 12:24:25 PM

Document Has Been Signed on 06/02/2022 12:24 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLAGE AT NORTHRIDGE, THE		FACILITY NUMBER:	197608838
ADMINISTRATOR:	BRADLEE ANN FOERSCHNER		FACILITY TYPE:	740
ADDRESS:	9222 CORBIN AVE		TELEPHONE:	(818) 350-2951
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	125	CENSUS: 92	DATE:	06/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Bradlee Ann Foerschner		TIME COMPLETED:	12:40 PM

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On 06/2/22 at 11:00 a.m., Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff at the front desk. LPA later met with Administrator Bradlee Ann Foerschner and the purpose of the visit was explained.

Upon arrival, LPA observed the following:

Infection control: Covid-19 infection control signage was observed outside of the facility. Proper signage was also observed inside in the common areas. Upon entrance, LPA was asked to check in, using the system Accushield. The system was designated to follow infection control practices. LPA observed staff wearing masks inside the facility, staff and Administrator also reminded residents to wear masks. Facility has sufficient PPE supplies for more than 30 days. A physical tour was conducted at 11:20 a.m. Fire Alarms are located throughout the facility the latest performance report from LAFD shows it is valid until 01/31/2023. Carbon Monoxide alarms are located throughout the facility and are operable. Common Areas: These include the dining areas, activity rooms, and other shared spaces. All common areas were observed to be cleaned and properly furnished. Facility maintains a comfortable temperature of 76.0 F. Common bathrooms were observed to have trash cans with lids and infection control prevention signs posted. Facility has a designated laundry area. Facility has a designated medication room that is kept inaccessible to residents. Kitchen area was toured, and LPA observed there to be sufficient one-week non-perishable foods and two days perishable food for all residents.

(cont. on 809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT NORTHRIDGE, THE	FACILITY NUMBER: 197608838
	VISIT DATE: 06/02/2022

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Bedrooms were randomly selected to tour and were observed to have appropriate furniture. Bathrooms were observed to have grab bars and non-skid mats. Outside areas: LPs toured the outside area of the facility. LPA observed appropriate outdoor furniture, with various shaded areas for residents. There is a pool with a fence located outside that is designated for the independent living community.

Administrative: On May 11, 2022 the Woodland Hills Regional Office received an LIC200 from this facility requesting a change of capacity. The total requested capacity noted on the application is 194 residents, of which 100 can be non-ambulatory and 20 bedridden. To process this request, the Administrator submitted an LIC200, an updated facility sketch that that reflects changes such as the designated bedridden bedrooms, and a check in the amount of $25.00 addressed to the Department. Based on today’s visit, LPA did not observe any issues or concerns with the request to change capacity. Our office will process the change request and the Administrator will be notified by the Fire Marshall when they are ready to schedule an inspection.

No deficiencies issued during today’s visit. Report was signed and delivered. An exit interview was conducted with the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 06/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/02/2022

LIC809 (FAS) - (06/04)

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