197609947-1-3-2024-31-AS-GSAO-CZ5QM9-20240103111711

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609947
Report Date: 01/03/2024
Date Signed: 01/03/2024 11:17:21 AM

Document Has Been Signed on 01/03/2024 11:17 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	PRIMROSE 3		FACILITY NUMBER:	197609947
ADMINISTRATOR:	NAIMUDDIN, MUBEEN		FACILITY TYPE:	740
ADDRESS:	17537 BLYTHE STREET		TELEPHONE:	(323) 872-2755
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 6	DATE:	01/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:45 AM
MET WITH:	Mubeen Naimuddin		TIME COMPLETED:	11:57 AM

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On 01/03/24, at 08:35 a.m., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with caregiver Janet Araba and disclosed the purpose of the visit. The administrator- Mubeen Naimuddin was called and arrived about fifteen (15) minutes later.

LPA asked for the census, resident, and staff rosters.

The facility tour started 09:20 a.m. Temperature of facility wall thermostat is observed and set to 75 degrees Fahrenheit.

Medications-LPA observed medication stored in cabinet locked and secured in the kitchen area inaccessible to residents.

Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. Sharps are stored and locked in one of the cabinets in the kitchen on the right side of the sink. Toxins are kept secured and locked in one of the cabinets under the kitchen sink inaccessible to residents. There is one fire extinguisher located against the wall in the kitchen area fully charged and dated February 2023. There were two (2) complete first aid kits stored in overhead cabinet in the kitchen.

There is a backyard which has outdoor furniture and grassy area for outdoor activities. There is no pool.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

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: PRIMROSE 3	FACILITY NUMBER: 197609947
	VISIT DATE: 01/03/2024

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The garage is attached to the house and was observed to be locked and used to store toxins, washer, and dryer. There is also one (1) refrigerator in the garage with extra food.

Bedrooms: There is five (5) resident bedrooms. There are two bedrooms that have their private bathroom and are single occupied. One bedroom that is shared and the other bedroom that is single, occupied. All five (5) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. There is one bathroom that is located by the entrance of the facility that is used by staff and residents. The bathroom temperature of the water are within regulations. It reads between 115.5-118.9 Fahrenheit.

Living and dining room furniture is accessible for five (5) residents. There is a television, telephone line and enough seating for five (5) residents. Furniture was observed to be in good condition and there is no fireplace. The smoke/carbon monoxide detectors are hardwired and interconnected and were tested. They were functional.

Administrative: There is an annual fee due which is due as of 11/2023 for $745.00. The Insurance plan is updated, disaster plan, administrator certificate, Designation of facility responsibility, Admission Agreement, Personal Rights, Staff LIS and resident rights signs are against the wall at the entrance of the facility.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2024

LIC809 (FAS) - (06/04)

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