197609935-1-21-2024-31-AS-JGTN-CZPRRC-20240121121455

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609935
Report Date: 01/21/2024
Date Signed: 01/21/2024 12:15:10 PM

Document Has Been Signed on 01/21/2024 12:15 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LAKESIDE VIEW ELDERLY CARE		FACILITY NUMBER:	197609935
ADMINISTRATOR:	DUENAS, RALPH		FACILITY TYPE:	740
ADDRESS:	14003 LAKESIDE ST		TELEPHONE:	(818) 288-5869
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	6	CENSUS: 5	DATE:	01/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:52 AM
MET WITH:	Ronald Paison - Staff		TIME COMPLETED:	12:15 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	Licensing Program Analyst (LPA) Gary Tan, met with staff Ronald Paison for a One (1) Year Required visit for this facility. LPA arrived and was greeted by Ronald who called the administrator and informed the purpose of the visit. Assistant Administrator Emiliano Siapno designated Mr. Paison to sign the report. There is only one entrance being utilized at the facility, there are required poster 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 and Infection Plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. A tour of the physical plant was conducted with Mr. Paison at 9:36 AM. The facility is a single storey building with six (6) private bedrooms and five (5) bathrooms currently occupying five (5) residents. The facility is fire cleared for six (6) non-ambulatory residents, all of which may be bedridden. Hospice waiver for six (6) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with dining The facility maintains a comfortable temperature at 74°F. The smoke detectors are hardwired and inter connected and observed to be operational. The fire extinguishers were filled and last bought on 03/14/23. The facility is equipped with sprinkler system. There is a carbon monoxide detector installed at the facility.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2024

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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LAKESIDE VIEW ELDERLY CARE	FACILITY NUMBER: 197609935
	VISIT DATE: 01/21/2024

NARRATIVE

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The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility. The backyard has a big tool shed. The garage is attached to the home and was locked and inaccessible to residents during the visit. The garage is also used as a stock room for emergency foods and as a laundry area.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies including detergents and pesticides and other toxins are stored in garage. Knives and sharps are observed to be kept in a locked drawer in the kitchen.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 111.5°F to 119.1°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet.

Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aids kits have complete tools and supplies.

Client records: Client records are reviewed and appeared to be complete and updated.

Staff records: LPA conducted a complete file review of staff record. Staff records appeared to be complete and updated.

Disaster drill was last conducted on 01/10/2024. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 01/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2024

LIC809 (FAS) - (06/04)

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