197609996-11-6-2023-31-AS-ADUA-CXC42D-20231106174257

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609996
Report Date: 11/06/2023
Date Signed: 11/06/2023 05:43:22 PM

Document Has Been Signed on 11/06/2023 05:43 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:	A CARING VILLA		FACILITY NUMBER:	197609996
ADMINISTRATOR:	CABANBAN, LILIA		FACILITY TYPE:	740
ADDRESS:	25421 VIA GRACIOSO		TELEPHONE:	(661) 254-6666
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91355
CAPACITY:	6	CENSUS: 5	DATE:	11/06/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:04 AM
MET WITH:	Lilia Flores Cabanban		TIME COMPLETED:	05:45 PM

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At approximately 10:30am Licensing Program Analyst (LPA), Abeye Duguma, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the Administrator, who granted access to the facility. At approximately, 10:45am physical tour was conducted with the Administrator and LPA observed the following:

Kitchen: LPA observed kitchen sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. The fire extinguisher was last serviced on 11/15/2022.

Bedrooms: There are three (3) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 115.8°F. LPA observed appropriate grab bar and non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom.

Medications: LPA observed medications are centrally stored and locked in the hallway closet and inaccessible to residents in care.

Common Areas: The facility maintains a comfortable temperature at 76°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. .

(CONT on LIC809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

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: A CARING VILLA	FACILITY NUMBER: 197609996
	VISIT DATE: 11/06/2023

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Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility and observed to be operational.

The garage: Laundry area is located in an attached garage and kept locked and inaccessible to residents. PPE supplies and food storage was also observed.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There are no bodies of water.

No health and safety hazards noted during the visit. A copy of the report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 11/06/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/06/2023

LIC809 (FAS) - (06/04)

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