197609670-4-18-2022-31-AS-RVAA-CDM2BS-20220418171538

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609670
Report Date: 04/18/2022
Date Signed: 04/18/2022 05:15:45 PM

Document Has Been Signed on 04/18/2022 05:15 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:	FAIR OAKS MANOR		FACILITY NUMBER:	197609670
ADMINISTRATOR:	BONZON, TED		FACILITY TYPE:	735
ADDRESS:	5035 ECHO ST		TELEPHONE:	(818) 846-4469
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90042
CAPACITY: 32		CENSUS: 31	DATE:	04/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:32 PM
MET WITH:	Shabaz Baig, Administrator		TIME COMPLETED:	05:12 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	Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year Infection Control inspection to the facility. LPA met with Administrator Shabaz Baig and explained the reason for the visit. A tour of the physical plant was conducted at 1:32 pm and the following was noted: There is only one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet and hand sanitizer are available. LPA was screened upon entry. The facility had submitted and approved Mitigation Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted throughout the facility. The facility has a designated visitors' area in the backyard. The facility has sufficient stock of PPE. The facility has fifteen (15) bedrooms and six (06) bathrooms currently occupying thirty-one (31) residents. All rooms are shared rooms. (continued on LIC 809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

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: FAIR OAKS MANOR	FACILITY NUMBER: 197609670
	VISIT DATE: 04/18/2022

NARRATIVE

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Dining room furniture was checked. The dining room is neat and clean. The facility maintains a comfortable temperature at 76 degrees. The smoke detectors are observed to be operational. There are carbon monoxide detectors. Fire extinguishers are located throughout the facility. They were purchased in April of 2022.

The backyard of the facility has outdoor furniture with a covered shaded area for residents. There is no body of water at the facility.

Laundry area is located by the kitchen where laundry detergents, cleaning agents and other toxins are stored.

Food Service/Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system.

The bathrooms were checked for cleanliness and proper operation. The hot water temperature was measured at 115.9 degrees F. There was enough clean linen available in stock in the closet.

Medications-LPA observed medication in an office to be locked and inaccessible to residents. There is one (1) complete first aid kit.

Exit interview conducted. A copy of this report was issued and signature obtained

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 04/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/18/2022

LIC809 (FAS) - (06/04)

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