197609986-5-29-2020-29-AS-ARIN-BQ2SAB-20200528134205

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609986
Report Date: 05/28/2020
Date Signed: 05/29/2020 11:20:49 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME:	ARBOR GROVE CARE		FACILITY NUMBER:	197609986
ADMINISTRATOR:	DOLMAN, ANDREW		FACILITY TYPE:	740
ADDRESS:	14819 VALERIO STREET		TELEPHONE:	(818) 809-2594
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY:	6	CENSUS: 0	DATE:	05/28/2020
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Andrew Dolman		TIME COMPLETED:	01:00 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) Aja Richardson conducted a Prelicensed visit at 11 am and met with the Administrator/Applicant Andrew Dolman. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted telephonically. This application is for a change of ownership Residential Care Facility for the Elderly with a capacity of six (5) non-ambulatory one bedridden. The facility is currently operating as Arbor Terrace Elderly Care - 197608093 with a current census of five (6). At 11 am, a tour of the physical plant was conducted. During the visit LPA observed the following: KITCHEN: The facility is equipped with a spacious kitchen that is supplied with adequate dining and cook ware. There are sufficient supplies of perishable and nonperishable food. Appliances and fixtures are clean and functional. The kitchen trash can was equipped with a lid. Cleaning supplies are kept in a locked cabinet. BEDROOMS: There are six (3) bedrooms, all are appropriately furnished for double occupancy. All bedrooms were supplied with all required bedding and linens. There is also one staff bathroom. There is sufficient lighting as well as closet and drawer space available. BATHROOMS: There is 1 full bathroom designated for resident use. Bathroom is properly equipped with grab bars and have night lights. There is sufficient supplies of towels, paper goods and personal hygiene supplies. Hot water delivered at 114. degrees F.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2020

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, 6500 HOLLISTER AVE. SUITE 200
GOLETA, CA 93117

FACILITY NAME: ARBOR GROVE CARE	FACILITY NUMBER: 197609986
	VISIT DATE: 05/28/2020

NARRATIVE

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COMMON AREAS: These include a living space adjacent to the kitchen/dining area that is appropriately furnished and equipped with a television. There is a dedicated area for the posting of required documents during the front entry way.

LAUNDRY ROOM: There is a laundry room located in the unattached garage equipped with a washer and dryer that is inaccessible to residents. Cleaning supplies and personal hygiene supplies are located in this space.

STAFF AREA: There is a bedroom dedicated for staff use that is inaccessible to residents.

SURROUNDING GROUNDS: The property is equipped with fencing and gates . There is furniture appropriate for outdoor use including a covered patio providing shade.

Component III was completed during visit.

Exit Interview Conducted. Report emailed to Administrator.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Aja Richardson	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2020

LIC809 (FAS) - (06/04)

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