197609986-5-22-2022-29-AS-EPEI-CENRNP-20220522131040

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609986
Report Date: 05/22/2022
Date Signed: 05/22/2022 01:11:16 PM

Document Has Been Signed on 05/22/2022 01:11 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
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: 5	DATE:	05/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:58 AM
MET WITH:	Andrew Dolman, Administrator		TIME COMPLETED:	01:15 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 11:58 a.m., LPA was greeted and screened by staff. At 12:24 p.m., the Administrator, Andrew Dolman arrived at the facility. This annual had a specific emphasis on infection control practices and procedures. At 12:30 p.m., the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 12:37 p.m., hot water measured at 111.4-degree Fahrenheit. COMMON AREAS: The LPA observed common area to be relatively clean and properly furnished. At 12:00 p.m., the LPA observed the fire extinguishers to be fully charged and last serviced on 08/23/2021. Flashlights were observed throughout the facility. Upon entry, signs are posted to promote handwashing, cough/sneeze etiquette, and physical distancing. At 12:31 p.m., fire alarms and carbon monoxide detectors were tested and functioned properly. OUTDOOR SPACE: At 12:36 p.m., the LPA observed the backyard, which has a covered outdoor area for resident use. There are two gates with latches designated for an emergency exits. There are no bodies of water on the premises at the time of the visit. The garage is locked and detached to the house and laundry units are located inside the garage. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2022

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: 05/22/2022

NARRATIVE

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KITCHEN: At 12:38 p.m., the LPA observed the kitchen/dining area. Knives are stored in a locked drawer. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 12:43 p.m., hot water measured at 106.5-degree Fahrenheit. Medications and first aid kits are located in a locked file cabinet near the kitchen area. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away.

INFECTION CONTROL: During today’s visit, the LPA 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 facility’s cleaning protocol is sufficient. 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.

No deficiencies were observed at this time. Exit interview conducted with the Administrator. Report issued and a copy of the report was emailed to the Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 05/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/22/2022

LIC809 (FAS) - (06/04)

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