197609990-3-3-2022-31-AS-TSMH-CC6VHY-20220303152756

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609990
Report Date: 03/03/2022
Date Signed: 03/03/2022 03:28:02 PM

Document Has Been Signed on 03/03/2022 03:28 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	AMENA LOVE BOARD AND CARE		FACILITY NUMBER:	197609990
ADMINISTRATOR:	JONES, MERCER		FACILITY TYPE:	740
ADDRESS:	10751 VIKING AVE		TELEPHONE:	(747) 239-3247
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91326
CAPACITY:	6	CENSUS: 3	DATE:	03/03/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Mercer Jones, Administrator		TIME COMPLETED:	03:25 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) Tihesha “Lynn” Smith conducted an unannounced Required One (1) year-Infection Control inspection to the above facility. LPA was greeted by Administrator Mercer Jones and explained the reason for the visit. A tour of the physical plant was conducted between: 11:20 am and 12:45 pm and the following was observed: Signs to wear a mask were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathrooms and on message board. Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 74 degrees. The smoke detectors are hardwired and interconnected and observed to be functional. Current fire extinguisher with receipt attached was observed. Kitchen area was sufficiently stocked with two (2) days of perishable and seven (7) days of non-perishable food. Sharps are stored in a locked lower cabinet. Medications: LPA observed medication in lower kitchen cabinet to be locked and inaccessible to residents. There was one (1) complete first aid kit stored lower kitchen cabinet.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: AMENA LOVE BOARD AND CARE	FACILITY NUMBER: 197609990
	VISIT DATE: 03/03/2022

NARRATIVE

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(CONT FROM 809)

Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. One (1) resident currently isolated in C19 quarantine.

Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. LPA measured the hot water between the required limit of 105-120 degrees Fahrenheit during time of visit.

Laundry area is located inside the garage which were observed to be locked. The facility has sufficient stock of PPE locked in a cabinet inside the garage.

The facility grounds were free of hazards and the backyard has outdoor furniture with umbrella for shade.

LPA reviewed files for the three (3) residing residents. All resident files contained medical assessments, physician orders for medications and centrally stored medication logs. Staff files were also inspected. All staff files inspected had current first aid/ CPR documentation as well as the appropriate training documentation. Medications are given as prescribed.

Exit interview conducted/Copy of this report given.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 03/03/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/03/2022

LIC809 (FAS) - (06/04)

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