197609901-1-5-2022-31-AS-RVAA-CAE2GR-20220105162333

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609901
Report Date: 01/05/2022
Date Signed: 01/05/2022 04:23:49 PM

Document Has Been Signed on 01/05/2022 04:23 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:	CRESCENT HILLS		FACILITY NUMBER:	197609901
ADMINISTRATOR:	VALDEZ, ABRAHAM R		FACILITY TYPE:	735
ADDRESS:	3350 SANTA CARLOTTA		TELEPHONE:	(818) 456-7174
CITY:	LA CRESCENTA	STATE: CA	ZIP CODE:	91214
CAPACITY: 4		CENSUS: 4	DATE:	01/05/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:35 PM
MET WITH:	Mathew De Vera, Assistant Administrtor		TIME COMPLETED:	04:30 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 Assistant Administrator Mathew De Vera and explained the reason for the visit. A tour of the physical plant was conducted at 2:45 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, hand sanitizer, gloves, and masks 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 in the garage. The facility has four (4) bedrooms and three (3) bathrooms currently occupying four (04) residents. One (01) room is shared. One room is for staff. (continued on LIC 809-C

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE:	DATE: 01/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022

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: CRESCENT HILLS	FACILITY NUMBER: 197609901
	VISIT DATE: 01/05/2022

NARRATIVE

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Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 72 degrees. The smoke detectors are observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguishers are located in the kitchen and by the washer and dryer.

The backyard of the facility has outdoor furniture with a covered shaded area for residents. There is no body of water at the facility. There is also a garage where extra food, P.P.E. and hazardous chemicals are stored.

Laundry area is located next to the living room, laundry detergents, cleaning agents and other toxins are stored inside the garage which is kept locked.

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. Hallways/passage ways are lit.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 117.0 degrees. There was enough clean linen available in stock in the cabinets.

Medications-LPA observed medication inside one of the kitchen cabinents 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: 01/05/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/05/2022

LIC809 (FAS) - (06/04)

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