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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610006
Report Date: 07/20/2022
Date Signed: 07/20/2022 12:09:55 PM


Document Has Been Signed on 07/20/2022 12:09 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:NORTHRIDGE VILLA FOR ELDERLY, INC.FACILITY NUMBER:
197610006
ADMINISTRATOR:WIJERATHNA, RONIKAFACILITY TYPE:
740
ADDRESS:8419 YOLANDA AVENUETELEPHONE:
(818) 812-9599
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY:6CENSUS: 5DATE:
07/20/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Nita WimalarapneTIME COMPLETED:
12:20 PM
NARRATIVE
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On 7/20/22 at 10:30 a.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by staff member. LPA arrived at the same time as another visitor and neither the visitor or the LPA were screened for infection control and staff were observed to not be wearing masks. LPA observed covid-19 signage, hand sanitizer and a hand washing station but no staff instructed the visitor or the LPA to use any.

LPA notified the Administrator that an annual inspection will be conducted. Administrator stated she lives two hours away and will not be able to come to today's visit. Administrator designated staff Nita to sign this report.

A physical plant tour was initiated at 10:45 a.m. Upon conducting a tour, LPA observed two (2) fire extinguishers to be expired, the last service was done in 2019. LPA also observed the air conditioner temperature to be 80 degrees Fahrenheit. LPA observed sufficient supply of food. Chemicals and knives were kept inaccessible to residents in care. A locked closet in the hallway stores resident medications and canned goods. LPA toured bedrooms (5) and three (3) bathrooms. All have adequate lighting, furniture and extra linens. Trash cans have closed tight fitting lids. Extra towels and linens were readily available. The backyard is clean, has a covered shaded area. No body of water.

Deficiencies were issued per CA code of Regulations Title 22. See 9099D's included with this report. Appeal rights issued. Report signed and delivered. Exit interview conducted.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
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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Document Has Been Signed on 07/20/2022 12:09 PM - It Cannot Be Edited

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: NORTHRIDGE VILLA FOR ELDERLY, INC.
FACILITY NUMBER: 197610006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87470(c)
87470(c) Infection Control Requirements shall be developed by the licensee... (1) The Infection Control Plan shall include: (F) Staff shall demonstrate knowledge... appropriate to the job assigned and as evidenced by safe and effective job performance.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observations the licensee did not ensure staff complied with the cited section by not screening visitors for symptoms of COVID 19 upon entry and staff where not wearing masks, which poses and immediate Health and Safety and personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Licensee/Administrator and all staff will attend infection control training to be provided by an individual trained in infection control. Administrator is to have a designated staff screening all visitors for Covid-19 upon arrival. Proof of training and designation of staff shall be emailed to LPA no later than 7/22/22.
Type A
Section Cited
CCR
8
Fire Clearance 80020 (a) All facilities shall secure and maintain a fire clearance approved by the city or county fire department, the district providing fire protection services, or the State Fire Marshal.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in which the fire extinguisher was observed to have a service date of 2019 which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2022
Plan of Correction
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Licensee/Administrator will purchase a new fire extinguisher or have the current one serviced and ensure that the fire extinguisher is updated annually. Administrator will send proof of purchase or service to LPA via email no later than 7/22/22.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
Page: 2 of 3


Document Has Been Signed on 07/20/2022 12:09 PM - It Cannot Be Edited

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: NORTHRIDGE VILLA FOR ELDERLY, INC.
FACILITY NUMBER: 197610006

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(b)
87303 Maintenance and Operation (b) A comfortable temperature for residents shall be maintained at all times.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as upon arrival, LPA observed the thermometer to reflect an indoor temperature of 80 degrees faranheit which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/25/2022
Plan of Correction
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The licensee/administrator will ensure staff maintain a daily temperature log. Proof of the log will be sent to the LPA by the POC due date 7/25/2022.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Nichelle GillyardTELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Melissa RuizTELEPHONE: (818) 401-7980
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2022
LIC809 (FAS) - (06/04)
Page: 3 of 3