197609341-9-27-2024-31-AS-NRED-D9HU2Y-20240927151244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609341
Report Date: 09/27/2024
Date Signed: 09/27/2024 03:13:15 PM

Document Has Been Signed on 09/27/2024 03:13 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:	JACKIE'S HIDEAWAY B		FACILITY NUMBER:	197609341
ADMINISTRATOR:	TAL, TALY		FACILITY TYPE:	740
ADDRESS:	5929 DONNA AVE		TELEPHONE:	(818) 344-0501
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 6	DATE:	09/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:55 AM
MET WITH:	Andrie Alvarez		TIME COMPLETED:	03:10 PM

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At approximately 11:55 a.m. on 09/27/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the administrator and disclosed the reason for the visit.

The facility was last visited on 08/26/22 for an annual visit. It is a single story building with six (06) bedrooms, six (06) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden in Bedroom #2. The facility serves residents with dementia. Approved hospice waivers for six (06). Surveillance cameras are used in exterior areas.

The front entrance is gated and unlocked from the inside. The front yard is maintained. At the front door, LPA observed postings for the house rules, facility sketch, facility license, COVID precautions, rights of resident councils, ombudsman contacts, confidential complaint contacts, and oxygen in use signs. Additional postings were observed for the emergency disaster plan, personal rights, and administrator certificates. A screening station at the front contained a visitor log, sanitizer, and masks. Walls, floors, windows, screens, and blinds were clean and in good repair. A fireplace was appropriately covered. The living room contained a television, reading materials, and furniture in good repair. At 12:20 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. At 12:25 p.m. the carbon monoxide detector in the hallway was tested and deemed operational. At 12:30 p.m. smoke detectors were tested and operational. At 12:35 p.m. LPA observed a fully-stocked first aid kit near the kitchen. It was purchased on 08/08/24.

The facility has six (06) bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All beds with wheels were in the locked position. Exit doors from rooms were unlocked. The facility has six (06) bathrooms. Bathrooms contained liquid soap, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 12:45 p.m. LPA measured the water temperature to be 108.0 degrees Fahrenheit in the private bathroom to Bedroom #2. At 1:00 p.m. the house telephone was called and deemed operational.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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: JACKIE'S HIDEAWAY B	FACILITY NUMBER: 197609341
	VISIT DATE: 09/27/2024

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Nine (09) out of nine (09) auditory alarms were on and functional. The seating area in the rear was shaded. The back yard also contained a gardened area. Emergency exit paths were free of hazards. The exit gate was unlocked. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator, freezer, and pantry. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked below the sink. Medications were locked above the counter top. The laundry area was near the kitchen and contained a washing machine and a dryer in working order. Detergents were locked in a cabinet.

At 1:20 p.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit.

During today’s inspection, no immediate health or safety hazards were observed.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC809 (FAS) - (06/04)

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