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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609767
Report Date: 08/10/2023
Date Signed: 08/10/2023 02:40:08 PM


Document Has Been Signed on 08/10/2023 02:40 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: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:
08/10/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Florence Peregrino-AdministratorTIME COMPLETED:
03:15 PM
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On 08/10/23 Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by the Administrator Florence Peregrino and explained the reason for the visit. A tour of the physical plant was conducted at 09:45 AM.
Bedrooms: There were five (5) bedrooms designated for residents' use. Four (4) bedrooms are private and one (1)shared. All bedrooms were clean, properly furnished and had sufficient lighting.
Bathrooms: There were four (4) bathrooms in the facility. One (1) bathroom in hallway near front of house and three (3) bathrooms in the private bedrooms. All bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was 111.3 degrees Fahrenheit. Cleaning supplies were kept in locked cabinets.Temperature: Facility maintains a comfortable temperature of 78 degrees Fahrenheit.
Smoke Alarms and Carbon Monoxide: detectors were tested and function properly. There were 2 fire extinguishers at the facility and they were purchased on 08-10-2023.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives and detergents were stored in locked drawers and cabinets. Medications are locked in separate 3-tier cabinets against kitchen wall. Medications observed to be locked and inaccessible to clients. LPA observed fully stocked first aid kit locked in top cabinet with facility, staff and client files.
Surrounding Grounds: Entry/exits were observed to be locked. The outdoor area was clean and free of hazards. There is large deck with a patio table and chairs shaded by a large umbrella for clients use in the backyard. Patio furniture observed to be in good repair with adequate seating for the residents. There are two (2) locked sheds in the backyard observed to be storing equipment and boxes.
Laundry Area: located through kitchen to the left of refrigerator. Appliances observed to be in good repair. All laundry detergents were locked under the kitchen sink.
No deficiencies issued during today’s visit.Report was signed and delivered and an exit interview was conducted.
SUPERVISOR'S NAME: Eva MillerTELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Mariana AgbanTELEPHONE: 818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE: 08/10/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/10/2023
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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