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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608984
Report Date: 07/02/2024
Date Signed: 07/02/2024 11:18:25 AM


Document Has Been Signed on 07/02/2024 11:18 AM - 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:INFINITY ELDER CARE INCFACILITY NUMBER:
197608984
ADMINISTRATOR:DIVINIA C. CRUZFACILITY TYPE:
740
ADDRESS:9253 BALCOM AVETELEPHONE:
(818) 813-1736
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY:6CENSUS: 2DATE:
07/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
08:50 AM
MET WITH:Raul Cruz- CaregiverTIME COMPLETED:
11:25 AM
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On 07/02/2024 at 08:50 AM, Licensing Program Analyst (LPA) Gina Saucedo conducted an unannounced, Annual Inspection and met with caregiver Raul Cruz. LPA asked for the census, staff and resident files.

The physical plant was toured inside and out at 9:50 am.

Bedrooms: All six (6) bedrooms are single, occupied. There is five (5) resident bedrooms and one (1) staff bedroom. LPA observed rooms to have bedding sheets, pillowcase, blankets, nightstands, televisions, and sufficient lighting for each of the residents sharing the room. In between the bedrooms there are cabinets filled with extra linen. There is also a pantry on your left-hand side of the entrance of the facility that is filled with extra chemicals locked and inaccessible to the residents.

Bathrooms: There are three (3) bathrooms that were toured and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured within regulations of 116 degrees Fahrenheit and 118. The showers have non-slip bathmats and grab bars.

Medications were kept in a locked in a large, white cabinet in the kitchen. All medications were properly labeled and inaccessible to residents. There is a complete first aid kit located in the same large, white cabinet in the kitchen.

Kitchen Area: LPA inspected the kitchen area. There are two (2) refrigerators which were clean and in good operation. Knives and sharp objects were kept stored and locked in a cabinet located in the middle of the kitchen island on your left-hand side inaccessible to the residents. LPA observed sufficient supply of seven (7) day non-perishable and perishable foods in the cabinet. There are two (2) fire extinguishers fully charged and one (1) expires 07/25/2024.

809C-continued

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:
DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/02/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: INFINITY ELDER CARE INC
FACILITY NUMBER: 197608984
VISIT DATE: 07/02/2024
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Living/Dining Room Area: LPA Saucedo observed the living room furniture to be clean and in good repair. The facility maintains a comfortable temperature at 75 degrees Fahrenheit with a large television. The other side of the living room also has furniture and another television with the telephone line access.

Outside: LPA toured the outside area. LPA observed a covered shaded area for residents and appropriate outdoor furniture. The facility has no body of water on the premises. There is one gate that is unlocked leading to the outside area towards the street. There are also ramps provided for the residents. There are two (2) sheds that LPA was able to observe where there is extra storage. The washer and dryer are located outside.

The carbon monoxide and the smoke detector were tested, and they were operable. The facility does have a signal system.

Garage: The garage is attached to the facility there is an access door from the kitchen area. It is used for additional storage of food and resident property.

Administration: The Infection control was reviewed. It is in a binder with the daily plan activities, Liability Insurance which expires 08/01/2024 and fire drill. There is another binder that has the Mandated Reporter Information, Theft and Loss, Emergency Numbers and House Rules. The Covid 19 signs are against the wall on your right-hand side of the entrance of the facility, hygiene sanitation signs, Emergency and Disaster Plan, Rights Personal Rights, YES sign, Approved Hospice Sign and Resident Bill of Rights.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the Caregiver.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina SaucedoTELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:

DATE: 07/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/02/2024
LIC809 (FAS) - (06/04)
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