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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609057
Report Date: 01/05/2022
Date Signed: 01/05/2022 11:29:29 AM

Document Has Been Signed on 01/05/2022 11:29 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PRIMROSE 2FACILITY NUMBER:
197609057
ADMINISTRATOR:NAIMUDDIN, MUBEENFACILITY TYPE:
740
ADDRESS:8115 DE SOTO AVETELEPHONE:
(323) 387-2755
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 6CENSUS: 6DATE:
01/05/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Mubeen NaimuddinTIME COMPLETED:
11:30 AM
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Licensing Program Analysts (LPA) Eleza Jackson conducted an unannounced annual inspection using the Infection Control Tool. Mitigation plan was reviewed. A physical tour was conducted at and the following was observed: Infection Control: Upon arrival, Jean Amorso took LPA Jackson’s temperature and was asked LPA to sign the visitors’ log. Proper signage was observed inside of the facility. Administrator stated they need PPE supplies for residents and staff. LPA Jackson documented request and advised that he can arrange for a contactless pick for supplies. Food Inspection: LPA Jackson observed there to be sufficient supply of perishable and non perishable foods. Food storage and preparation appear to be clean and inaccessible to pests. Smoke detectors/carbon monoxide tested; deemed to be in operating condition. Fire extinguisher is up to code. Resident rooms: All residents bedrooms were properly furnished with appropriate bedding, sufficient lighting, and the room appeared to be clean. Bathrooms: LPA Jackson observed appropriate hand washing signs posted in the bathroom. Laundry service: LPA Jackson observed that the facility uses the laundry machines at Primorse; located next door, cleaning products/chemicals are inaccessible to residents. Medications are centrally stored and locked. Outside areas: LPA toured the outside area of the facility. LPA observed that the facility has a shared backyard with Primrose; located next door, and it has appropriate outdoor furniture, with a covered shaded area for clients. No deficiencies issued. Exit interview conducted.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Eleza Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 01/05/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/05/2022
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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