197609767-7-26-2022-31-AS-TSMH-CGPVMP-20220726163352

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609767
Report Date: 07/26/2022
Date Signed: 07/26/2022 04:34:00 PM

Document Has Been Signed on 07/26/2022 04:34 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:	ASSURE CARE VILLA		FACILITY NUMBER:	197609767
ADMINISTRATOR:	PEREGRINO, FLORENCE		FACILITY TYPE:	740
ADDRESS:	8854 OAKDALE AVE		TELEPHONE:	(747) 237-2345
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6		CENSUS:	DATE:	07/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Dennis Bomifacio		TIME COMPLETED:	04:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced Annual Required/infection control visit to this facility at 1:45 pm. LPA Smiths’ temperature taken upon entry and Covid symptoms questions asked by caregiver Anabelle Dulay. LPA informed staff the purpose of this visit. The administrator was called at 1:50 pm. Administrator was called again at 3:30 pm and authorized House Manager Dennis Bonifacio to sign report.

LPA conducted a tour at 2:35 PM of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA was escorted to the living and dining combination area and observed adequate seating for residents. Staff confirmed there are six (6) clients in the home. The living area had furnishings, sufficient lighting and the area was clean.

Smoke alarms and carbon monoxide detectors were present and function properly. The fire extinguisher is located in living room and observed to be charged.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the six (6) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk and eggs observed with juice. The freezer is stocked with meats. Canned food stored in wood cabinet in kitchen against wall and extra water on floor next to canned food cabinet

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.

(Cont to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

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: ASSURE CARE VILLA	FACILITY NUMBER: 197609767
	VISIT DATE: 07/26/2022

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(Cont from 809)

Sharps observed to be locked in drawer to the right of kitchen sink and inaccessible to clients. All the toxins, cleaning solutions and disinfectants are locked under kitchen sink. Laundry area located through kitchen to the left of refrigerator. Appliances observed to be in good repair.
There are five (5) bedrooms. A tour of the client’s bedrooms, bathrooms, personal accommodations, and common areas (all resident bedrooms toured had the required furniture for residents’ comfort and safety). Common areas were observed for the ability to safely serve the needs of residents, including cleanliness, skid materials, locks, grab bars, and comfortable temperatures. LPA observed a sufficient supply of linens in pantry closet across from refrigerator and PPEs stored on baker’s rack.

There are four (4) bathroom; one (1) bathroom in hallway near front of house and three (3) bathrooms in the private bedrooms. Each bathroom has posted “wash your hands” sign and the following items available: hand soap, paper towels, and trash cans. The hot water temperature was measured for the four (4) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 108, 109.2, 111.4, and 112.7 degrees Fahrenheit.

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. LPA requested a copy of infection control plan which will be sent by email.

There were no immediate health and safety hazard observed during the day of inspection. There are no deficiencies to report.

Exit interview conducted and a copy of this report was given.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2022

LIC809 (FAS) - (06/04)

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