197609023-11-23-2022-31-AS-NRED-CLFS5S-20221123123449

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609023
Report Date: 11/23/2022
Date Signed: 11/23/2022 12:35:00 PM

Document Has Been Signed on 11/23/2022 12:35 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:	PRIMROSE		FACILITY NUMBER:	197609023
ADMINISTRATOR:	MUBEEN NAIMUDDIN		FACILITY TYPE:	740
ADDRESS:	8107 DE SOTO AVE		TELEPHONE:	(323) 387-2755
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91304
CAPACITY:	6	CENSUS: 5	DATE:	11/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Mubeen Naimuddin		TIME COMPLETED:	12:40 PM

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At 10:45 a.m. on 11/23/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later Administrator and disclosed the reason for the visit. LPA and staff toured the facility inside and out.

The facility was last visited on 10/04/2022 for a case management visit. It is a single story building with 5 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents, of which 1 may be bedridden. Approved hospice waivers for 6.

Upon entry, LPA observed a maintained front yard. The entry gate was unlocked. A ramp in good condition led to the main entrance. The facility’s masking and visitation policies were posted at the front. Cameras are used at the main entrance and in common areas. The screening station contained a visitor log, surgical masks, and 3 bottles of hand sanitizer. A PPE cart was also present at the front. Postings included facility license, Administrator certificate, facility sketch, emergency disaster plan, Ombudsman contacts, and confidential complaint contacts.

Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 11:05 a.m. LPA measured the room temperature to be 69 degrees Fahrenheit.

The facility had 6 bedrooms. All bedrooms were private. One bedroom is designated as a staff bedroom. The staff bedroom was free of hazards. Bedroom #3 was vacant. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. 6 out of 6 auditory alarms were on and functioning. Exits were unlocked and free of obstructions. A ramp in good condition with sturdy hand rails led out from Bedroom #1. Bedroom #3 also had a ramp in good condition. Bedroom #5 had a sign for “No Smoking – Oxygen in use”. The resident successfully tested the call system at approximately 11:40 a.m.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

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: PRIMROSE	FACILITY NUMBER: 197609023
	VISIT DATE: 11/23/2022

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The facility had 2 bathrooms. The resident bathroom by Bedroom #5 contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 11:44 a.m. LPA measured the water temperature to be 114 degrees Fahrenheit.

LPA observed an adequate supply of perishable and non-perishable food in the kitchen. The stove hood was clean, surfaces were sanitary, and appliances were functional. Sharps were locked below the countertop. Medications were locked above and below the counter. Cleaning solutions were locked below the sink. A laundry area was located near the kitchen. Detergents were locked.

All emergency exit paths were free from obstructions. Exit gates were unlocked. At 11:44 a.m. LPA tested the dual-purpose smoke and carbon monoxide detector to be operational. When tested, the fire door to Bedroom #2 automatically closed. At 11:20 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 10/12/2022.

Patio furniture outside was shaded by a canopy. The furniture was in good condition. The back yard had a gardened area with fruit trees. An additional unit contained workout equipment.

At approximately 11:15 a.m., 11:35 a.m., and 12:00 p.m., LPA interviewed 3 out of 4 staff. Staff presented no health, safety, or personal rights concerns. During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2022

LIC809 (FAS) - (06/04)

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