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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609342
Report Date: 06/19/2023
Date Signed: 06/19/2023 03:53:57 PM


Document Has Been Signed on 06/19/2023 03:53 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:LOS FELIZ GARDENSFACILITY NUMBER:
197609342
ADMINISTRATOR:SHAPIRO, NONNAFACILITY TYPE:
740
ADDRESS:205 E LOS FELIZ ROADTELEPHONE:
(818) 241-2273
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY:199CENSUS: 109DATE:
06/19/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Nonna Shapiro, Administrator TIME COMPLETED:
03:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Panushkina conducted a Case Management visit in conjunction with complaint #31-AS-20230616145625. LPA arrived at the facility at 10:20 AM. LPA met with Theresa Trinidad, Staff #1 (S1) and explained the purpose of the visit. Administrator arrived shortly after.

LPA and S1 conducted a physical plant tour at 10:50 AM.

At 11:05 AM, LPA conducted a visit into room #149 and observed six (6) Drawer Oak Double Dresser. LPA also observed that the top, right drawer was in disrepair.

Pursuant to the California Code of Regulations, Title 22, Division 6, Chapter 8, the following deficiency was observed and cited during the visit. See LIC 809-D.

Exit interview conducted, copy of this report and appeal rights issued.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
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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Document Has Been Signed on 06/19/2023 03:53 PM - It Cannot Be Edited

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: LOS FELIZ GARDENS
FACILITY NUMBER: 197609342

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/19/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/26/2023
Section Cited
CCR
87303(a)

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The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
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The Administrator agreed to have the drawer/dresser repaired immediately and will submit proof of repair on or before the POC date.
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Based on LPAs' observation, during physical plant tour, the licensee failed to ensure that the R1's six (6) Drawer Double Dresser is in good repair which poses a potential health and safety risk to the residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela PanushkinaTELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2023
LIC809 (FAS) - (06/04)
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