197609930-1-31-2024-31-AS-PKHN-CZZTTN-20240131140102

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609930
Report Date: 01/31/2024
Date Signed: 01/31/2024 02:01:22 PM

Document Has Been Signed on 01/31/2024 02:01 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VENTURA		FACILITY NUMBER:	197609930
ADMINISTRATOR:	CINDY GARCIA		FACILITY TYPE:	735
ADDRESS:	729 VENTURA ST		TELEPHONE:	(626) 529-3776
CITY:	ALTADENA	STATE: CA	ZIP CODE:	91001
CAPACITY: 4		CENSUS: 4	DATE:	01/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	CINDY GARCIA-ADMINISTRATOR		TIME COMPLETED:	02:15 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	At 10:10am Licensing Program Analysts (LPAs) Perchui Milena Khurshudyan and Ngo-Castaneda, Leslie conducted an unannounced annual inspection at the facility mentioned above. LPAs met with facility administrator Cindy Garcia, who granted access to the facility. At approximately, 10:20am physical tour was conducted LPAs observed the following: Bedrooms: At approximately 10:20am LPAs checked the bedrooms. There are four (4) bedrooms designated for 4 clients use. All rooms were observed to have sufficient lighting, and are properly furnished, clean and have appropriate bedding and linens. There is enough linens to be change every week or when necessary in a cabinet in the hallway. Bathrooms: At 10:25am LPAs observed two (2) bathrooms, all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. For bathroom #1 that is located beside bedroom #1 has a hot water temperature measured at 115°F. Bathroom #2 that is beside bedroom #3 in the hallway has a hot water temperature that measured 111.°F. LPAs observed appropriate grab bar and had non-skid mat. LPAs observed appropriate hand washing signs posted in each bathroom. All trash cans in bathrooms had fitted lids to protect from cross contamination. Kitchen: At approximately, 10:30am LPAs toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Canned non expired food was stored in kitchen pantries. All knives and sharps are observed to be locked in a locked staff room in locked drawer and inaccessible to residents. The facility has a working gas stove, microwave, refrigerator and freezer. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: VENTURA	FACILITY NUMBER: 197609930
	VISIT DATE: 01/31/2024

NARRATIVE

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Medications: At approximately, 10:35am LPAs observed medications are centrally stored and locked in the
cabinet, inside locked staff room by the living room area and inaccessible to residents in care. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

The laundry room is located by the kitchen area. LPAs observed all detergents locked and inaccessible to residents in care. There is a fire extinguisher by the kitchen area and in a hallway were last purchased on 12/09/2023.

Common Areas: The facility maintains a comfortable temperature at 68°F. The living room and dining area appeared clean and were properly furnished. The fireplace was closed and non-operational. No obstructions and or tripping hazards throughout the facility found. The office is located in the den. Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and observed to be operational. They are cleared for four (4) ambulatory clients. No issue with fire clearance.

Outside areas: At approximately, 10:50am LPAs toured the outside area of the facility. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. Exit area are free of obstructions and hazards. LPAs checked inside of the locked shed it was used for facility maintenance purposes. LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents. The facility does not have a swimming pool or body of water. There is no garage only parking port.

Between 10:15am to 12:20pm, LPAs reviewed records of four (4) clients and six (6) staff. Clients and staff
records appeared to be complete and updated.

Administrative: LPAs collected Administrator Certificate, infection control, LIC 500, LIC 9020, regional report, and surety bond.

No citations issued during this visit. Exit interview conducted. Copy of report printed and handed to Licensee.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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