197609986-6-8-2021-29-AS-EPEI-C3SRWC-20210608132254

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609986
Report Date: 06/08/2021
Date Signed: 06/08/2021 01:23:49 PM

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. #250
WOODLAND HILLS, CA 91364

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: 6	DATE:	06/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:22 AM
MET WITH:	ANDREW DOLMAN		TIME COMPLETED:	01:30 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 Analysts (LPAs) Emily Peraldi and Brian Balisi arrived at the facility unannounced to conduct a required annual visit at 11:20am. This annual had a specific emphasis on infection control practices and procedures. LPAs were greeted and screened by Administrator, Andrew Dolman upon entrance. The LPAs toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: The LPAs observed the kitchen/dining area at 11:25am. Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. OUTDOOR SPACE: The LPAs observed the backyard, which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid mat. Restrooms have adequate supply of paper towels. Hand washing signs are located in the restrooms. (Continued on LIC-809C).

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ARBOR GROVE CARE	FACILITY NUMBER: 197609986
	VISIT DATE: 06/08/2021

NARRATIVE

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(Continued from LIC-809)

Medications are in a locked file cabinet located near the dining area.

The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. A working telephone is present. There are activity supplies present.

The facility has postings upon entrance including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, cough etiquette and hand washing signs. Provider Informational Notices (PINs) are also posted upon entrance and throughout the facility.

INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

The LPAs observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Between 11:20am - 1:30pm LPAs conducted Infection Control mitigation module with Administrator.

Andrew also informed LPAs that not all staff have been fit tested for N95 respirators.

LPAs will provide Andrew with information and resources to have all staff fit tested for N95 respirators.

Exit interview conducted. Report issued and a copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 06/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/08/2021

LIC809 (FAS) - (06/04)

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