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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609023
Report Date: 03/02/2024
Date Signed: 03/02/2024 12:04:09 PM


Document Has Been Signed on 03/02/2024 12:04 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:PRIMROSEFACILITY NUMBER:
197609023
ADMINISTRATOR:MUBEEN NAIMUDDINFACILITY TYPE:
740
ADDRESS:8107 DE SOTO AVETELEPHONE:
(323) 387-2755
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY:6CENSUS: 5DATE:
03/02/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:03 AM
MET WITH:Mubeen Naimuddin - AdministratorTIME COMPLETED:
12:04 PM
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Licensing Program Analyst (LPA) Gary Tan, met with Administrator Mubeen Namuddin for a One (1) year required visit for this facility.

A tour of the physical plant was conducted at 9:23 AM and the following was noted:

There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Infection Control and Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has six (6) bedrooms and three (3) bathrooms currently occupying five (5) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for six (6) non-ambulatory resident, all of which maybe bedridden. Hospice waiver for six (6) residents.
Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings and doors were checked, the following was noted:

Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 74°F. Dual smoke and carbon monoxide detectors were tested and observed to be operational. There is a fire extinguisher located in the kitchen and was observed to be full and last inspected on 09/20/23. The facility is equipped with fire sprinkler system. The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility. (continued on LIC 9099-C)
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:
DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/02/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIMROSE
FACILITY NUMBER: 197609023
VISIT DATE: 03/02/2024
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(continued from LIC 809)

There is no garage at the facility. The garage was converted into a storage and staff quarter. It is also being used as storage for frozen foods, PPE and other toxins. Laundry room is located adjacent to the kitchen and was observed to be locked. All the laundry detergents, cleaning solutions, toxins and other chemicals are observed to be locked in a cabinet in the laundry room and locked cabinet under the sink.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days of non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All sharps and knives were also observed to be locked in the kitchen cabinet. The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. Sink in the bathrooms were removed and under construction. The hot water temperature measured at a range of 113.9°F to 115.1°F Towels and washcloths are not shared. There is enough clean linen available in stock at the cabinet.



Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. There is a complete first aid kit located in the medication cabinet.

Client records: Client records are reviewed. Residents records appeared to be complete and updated.
Staff records: LPA conducted a complete file review of staff records. Staff records appear to be complete and updated.

Disaster drill was last conducted on 02/21/24. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.
SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary TanTELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:

DATE: 03/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/02/2024
LIC809 (FAS) - (06/04)
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