<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609315
Report Date: 08/30/2022
Date Signed: 08/30/2022 01:29:19 PM


Document Has Been Signed on 08/30/2022 01:29 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:DE SOTO ELDERLY CARE FACILITY INCFACILITY NUMBER:
197609315
ADMINISTRATOR:SANDRA CARRIEDOFACILITY TYPE:
740
ADDRESS:7820 DE SOTO AVETELEPHONE:
(818) 462-3178
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY:6CENSUS: 1DATE:
08/30/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:50 PM
MET WITH:Sandra CarriedoTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 12:50 p.m. on 08/30/2022, 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 12/30/2021 for a case management visit. It is a single story building with 6 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 5 nonambulatory residents, of which 1 may be bedridden. Approved hospice waivers for 2. Facility postings included facility license, administrator certificate, Emergency Disaster Plan, theft and loss procedure, personal rights, confidential complaint contacts, ombudsman contacts, house rules, and COVID precautions.

The entrance is maintained and has a covered patio area. LPA was screened for infectious diseases upon entry. The screening station contained sanitizer, digital thermometer, and visitor log. The visitor log tracked symptoms and temperature. LPA advised to track vaccination status in the visitor log as well.

The facility has 6 bedrooms. 1 is private, 2 are shared, and 3 are designated for staff. All resident bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. The staff rooms were locked and free of hazards. The facility has 2 bathrooms. The resident bathroom 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. LPA observed an adequate supply of perishable and non-perishable food in the kitchen. Surfaces and appliances were sanitary and in good condition. Sharps were locked below the countertop. A laundry area was located near the kitchen. A functional washer and dryer were observed, and detergent was locked above the appliances. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 1:11 p.m. LPA measured the room temperature to be 78 degrees Fahrenheit. All emergency exit paths were free from obstructions. Exit gates were unlocked with inward facing latches.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:
DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/30/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3


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: DE SOTO ELDERLY CARE FACILITY INC
FACILITY NUMBER: 197609315
VISIT DATE: 08/30/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
At 1:00 p.m. LPA tested the hallway smoke detector to be operational. At 1:01 p.m. LPA tested the carbon monoxide detector in the hallway to be operational. The back yard was maintained and had furniture in good repair.

During today's inspection, the facility is in compliance with Title 22 regulations. No citations issued. Exit interview conducted. Copy of report issued.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 08/30/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3