197609534-4-18-2023-31-AS-MRUZ-CQZR3P-20230418124015

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609534
Report Date: 04/18/2023
Date Signed: 04/18/2023 12:41:08 PM

Document Has Been Signed on 04/18/2023 12:41 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:	AZALEA GARDENS		FACILITY NUMBER:	197609534
ADMINISTRATOR:	ABDELKADER,FOOREVER C.		FACILITY TYPE:	740
ADDRESS:	6231 AZALEA DRIVE		TELEPHONE:	(661) 422-6160
CITY:	QUARTZ HILL	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 1	DATE:	04/18/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:25 AM
MET WITH:	Christine Campbell		TIME COMPLETED:	12:50 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	On 4/18/2023 Licensing Program Analyst (LPA) Melissa Ruiz conducted an unannounced annual inspection. LPA was greeted by staff member (S1) and later met with Christine Campbell, facility administrator. LPA explained the purpose of this visit. A tour of the physical plant was conducted at 11:45 a.m. and the following was observed: The facility has one main entrance being used. There is a PPE screening station is located immediately upon entrance and had a table equipped with sufficient PPE readily accessible, a thermometer, hand sanitizer and sign in sheet at the time of visit. Visitors are required to wear mask. The facility has an approved mitigation plan on file and the Administrator submitted their infection control plan to LPA during this visit. The facility is a single-story dwelling and has five (5) bedrooms and three (3) bathrooms. A fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden. A hospice waiver for two (2) residents has been approved. Living and dining room furniture were checked. The living room is neat and clean along with the dining room. Furniture was observed to be in good repair and excellent condition. The facility maintains a comfortable temperature of 75°F. There are carbon monoxide and smoke detectors throughout the facility. A fire extinguisher is located at the dining area and observed to be full and has a date of purchase of 4/18/2023. (continued on LIC 809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

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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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: AZALEA GARDENS	FACILITY NUMBER: 197609534
	VISIT DATE: 04/18/2023

NARRATIVE

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Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in the kitchen drawer and inaccessible to residents.

Laundry room is located in by the hallway and laundry detergent, cleaning solutions and other toxins are observed to be locked inside the laundry room.

Bedrooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have sufficient amounts of personal hygiene products and are provided by the facility.

The Bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars and non-skid mats. Towels and washcloths are not shared. There are sufficient clean linens available in stock.

Medications: LPA observed medications in a kitchen cabinet and are kept locked and inaccessible to residents.

Garage: There is an attached garage that has a door from the laundry room.

The Backyard has covered shaded areas with outdoor furniture. There are no bodies of water.

Staff and residents’ records were reviewed and appeared to be complete and updated.

Administrative: Annual fees paid in full and are current as of today's visit.

Exit interview conducted. Copy of this report signed and issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa Ruiz	TELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2023

LIC809 (FAS) - (06/04)

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