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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609534
Report Date: 08/20/2024
Date Signed: 08/20/2024 01:59:28 PM


Document Has Been Signed on 08/20/2024 01:59 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364



FACILITY NAME:AZALEA GARDENSFACILITY NUMBER:
197609534
ADMINISTRATOR:ABDELKADER,FOOREVER C.FACILITY TYPE:
740
ADDRESS:6231 AZALEA DRIVETELEPHONE:
(661) 422-6160
CITY:QUARTZ HILLSTATE: CAZIP CODE:
93536
CAPACITY:6CENSUS: 2DATE:
08/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Khristine Campbell (administrator designee)TIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Evelin Rios conducted an unannounced One (1) year Required visit at this facility. LPA met with the administrator designee Khristine Campbell who granted access and LPA explained the purpose of the visit. The facility is a single-story dwelling with six (6) bedrooms of which five (5) are for resident use. The facility has an approved fire clearance for five (5) non-ambulatory and one (1) bedridden resident in Room #5 for a total capacity of 6. The facility has a Hospice waiver for two (2) residents.

While the administrator assisted residents with breakfast LPA reviewed two (2) of two (2) resident records to insure compliance with licensing forms. Records are kept locked in a kitchen cabinet. Centrally Stored Medication and Destruction Records were reviewed for proper documentation. Medication records are maintained manually. Facility keeps Medication Administration Records (MAR) as well.

A tour of the physical plant was conducted at 11:00 a.m. with the administrator designee and the following was observed: There is only one entrance being utilized at the facility, there are required postings posted by the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, and masks are available.

Kitchen: LPA conducted a tour of the kitchen and observed there to be sufficient supply of two day perishables and seven day non-perishables foods, properly stored. Food storage and preparation areas are clean and clear of clutter. LPA observed all knives, sharp object, locked in a kitchen drawer inaccessible to residents in care. There is one (1) fire extinguisher located in the kitchen observed to be fully charged with purchase date 04/30/2024. LPA observed the first aid kit with manual up to date in a kitchen drawer.
Common areas: LPA observed the living area and dining area to be clean. The furniture was in good repair and sits the capacity of the facility. Breakfast nook also stores games and crafts for residents to use.(Continue to LIC809-C)
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:
DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/20/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: AZALEA GARDENS
FACILITY NUMBER: 197609534
VISIT DATE: 08/20/2024
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(Continued from LIC809)
Bedrooms: LPA inspected five (5) out of five (5) resident bedrooms. Four (4) out of five (5) bedrooms are for private use. LPA observed each resident room to be properly furnished with beds, appropriate night stand, chair, bedding and with sufficient lighting and storage.

LPA observed the administrator designee test a dual smoke and carbon monoxide detector at 11:36 a.m. Detector are interconnected to other detectors located through out the facility. LPA observed detectors functioning properly. LPA observed door alarms on exit and entry doors on and functioning properly.

Bathrooms: The facility has three (3) bathrooms. One (1) is located in a resident's private bedroom. LPA observed all bathrooms to be clean and properly supplied with hand soap, toilet paper, paper towels and trash bins with lids. LPA observed non skid shower mats and proper grab bars by showers and toilets.

LPA observed a closet with emergency food, water and supplies for a disaster. LPA observed a linen closet with extra linens, and toiletries for the facility.

Laundry and Garage: Laundry room was observed locked. Detergents and cleaning supplies are kept locked in the laundry room. The garage can be accessed through the laundry room which is maintained locked.

Surrounding Grounds: Entry and exits were free of obstructions. There is a covered patio with appropriate furniture and fitness equipment for resident use. There are no bodies of water.

Staff Records: LPA reviewed staff records to insure compliance with licensing forms.

Medications: Centrally stored medications are maintained locked in a kitchen cabinet.


Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit Interview Conducted. A copy of this report provided.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin RiosTELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:

DATE: 08/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024
LIC809 (FAS) - (06/04)
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