<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609767
Report Date: 06/22/2021
Date Signed: 06/22/2021 11:35:04 AM

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:ASSURE CARE VILLAFACILITY NUMBER:
197609767
ADMINISTRATOR:PEREGRINO, FLORENCEFACILITY TYPE:
740
ADDRESS:8854 OAKDALE AVETELEPHONE:
(747) 237-2345
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 6DATE:
06/22/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Florence PeregrinoTIME COMPLETED:
11:45 AM
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) Tuesday Cabiness arrived at the facility 945am to conduct an unannounced infection control inspection/visit. LPA was greeted by caregiver Dennis Bonifacio, who allowed LPA to enter the facility. LPA observed residents eating breakfast and watching television in the living room. Upon entering the facility, there routine symptom screening was not initiated or conducted by the caregiver, and LPA was not requested to sign in the visitor’s book. Administrator Florence Peregrino was present, and LPA informed her the reason of the visit, and staff did not check temperature or request LPA to sign in the visitor's book. Administrator stated, she was not at the front door. LPA informed Administrator that all staff should be checking temperatures when individuals enter there facility. There have not been any active or past COVID cases at the facility since January 2021. There current census is (6), and all staff and residents have been vaccinated. LPA observed hand sanitizing station, and visitor sign in book at the front door. LPA observed Licensing COVID-19 posting inside the facility at the front door entrance, but no signs were posted outside. LPA informed Administrator, that signs should be posted outside of the facility, and there needs to be more signs posted throughout the facility. Administrator informed LPA, that she would post more signs.

The infection control inspection was conducted throughout the facility with the Administrator. The facility has (6) bedrooms; with (1) shared room and beds were kept (6) feet apart. All common areas were observed to be clean, including bathrooms, that had soap and towels. There were hand washing signs observed at the kitchen sink and all bathrooms. LPA conducted a mitigation plan review with the Administrator, to obtain information on how the facility has implemented the plan. Administrator reported they no longer conduct COVID-19 surveillance testing, since everyone has been vaccinated. Daily temperature for residents is performed daily, and LPA observed documentation. Visitation is conducted outside on the backyard patio. Residents eat together and practice social distancing at the dining room table. Administrator informed LPA, she received the PINs from the department, and conducts training to staff in relation to COVID-19. There are designated rooms for potential positive COVID residents. PPE, chemicals, cleaning supplies, and paper products were observed, with a viable supply.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
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: ASSURE CARE VILLA
FACILITY NUMBER: 197609767
VISIT DATE: 06/22/2021
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
26
27
28
29
30
31
32
LPA observed the facility has Licensing requirement for food supply. During the visit, the facility had sufficient staff; but LPA does have concerns, due to the number of residents that are bedridden and non-ambulatory. LPA had a discussion with the Administrator, who stated, she has back-up staff if needed. The facility has not had any positive COVID-19 reports for staff or residents. Administrator informed LPA that they continue to implement the best practices for their facility; which has kept them COVID-19 free since there first outbreak in January 2021. Staff have been trained and notified regarding sick and return to work policies. The facility is aware to report any changes with residents and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview and technical assistance (TA) violation was discussed with Administrator. Report signed during visit.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:

DATE: 06/22/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/22/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3