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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609930
Report Date: 11/18/2021
Date Signed: 11/19/2021 08:37:23 AM

Document Has Been Signed on 11/19/2021 08:37 AM - 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:VENTURAFACILITY NUMBER:
197609930
ADMINISTRATOR:SMITH, JAYFACILITY TYPE:
735
ADDRESS:729 VENTURA STTELEPHONE:
(855) 302-3331
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 4CENSUS: 0DATE:
11/18/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:35 PM
MET WITH:IVette Busby, ManagerTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year Infection Control inspection to the facility. LPA met with Manager Ivette Busby and explained the reason for the visit.

A tour of the physical plant was conducted at 2:40 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.

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 sufficient stock of PPE.

The facility has four (04) bedrooms and two (02) bathrooms currently occupying zero (0) residents. Four (04) rooms are private rooms.

(continued on LIC 809-C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Rosaura Valenzuela
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2021
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: VENTURA
FACILITY NUMBER: 197609930
VISIT DATE: 11/18/2021
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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 76 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 in the dinning area and were last purchased in July of 2021.

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 in the kitchen, laundry detergents, cleaning agents and other toxins were observed to be in accessible to residents.

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 bathroom was checked for cleanliness and proper operation. The hot water temperature was measured at 120 degrees. There was enough clean linen available in stock in the cabinets.

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: 11/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2021
LIC809 (FAS) - (06/04)
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