197610020-3-29-2024-31-AS-LNCA-D3TL7B-20240329083002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610020
Report Date: 03/28/2024
Date Signed: 03/29/2024 08:30:22 AM

Document Has Been Signed on 03/29/2024 08:30 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MONTARE AT THE LAKE		FACILITY NUMBER:	197610020
ADMINISTRATOR:	DENISE OJARIGI		FACILITY TYPE:	772
ADDRESS:	17801 TWILIGHT LANE		TELEPHONE:	(760) 409-1287
CITY:	ENCINO	STATE: CA	ZIP CODE:	91316
CAPACITY: 6		CENSUS: 4	DATE:	03/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:09 AM
MET WITH:	Danielle Sullivan- Program Director		TIME COMPLETED:	12:30 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 Analyst (LPAs) Leslie Ngo-Castaneda and Leizl De La Cerra conducted an annual required visit and inspection of the facility. LPAs was met with Ryan McCaffree who is the mental health worker was explained for the reason of the visit. At 9:30 AM Danielle Sullivan who is the program director met with LPAs and was explained the reason for the visit. At 10:20 AM, with the assistance of program director, LPAs took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen and the hallways. The charge date is 2/9/2024. During the visit the facility is at 70 degrees Fahrenheit. The facility is fire cleared for six (06) ambulatory residents. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPAs found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked in the cabinet. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in a cabinet below the sink. Bedrooms: There were five (5) bedrooms designated for residents' use. Bedroom #2, bedroom #3, bedroom #4 and bedroom #5 are private, but bedroom #1 is shared. The bedrooms that are used by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONTARE AT THE LAKE	FACILITY NUMBER: 197610020
	VISIT DATE: 03/28/2024

NARRATIVE

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Bathrooms: There are four and a half (4.5) bathroom designated for residents' and staff use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 115.6 degrees Fahrenheit for bathroom #1 located out bedroom #2. Bathroom #2 is inside bedroom #3. Hot water temperature was measured at 116.3 degrees Fahrenheit. Bathroom #3 is across bedroom #5. Hot water temperature was measured at 109.1 degrees Fahrenheit. Bathroom #4 is inside bedroom #5. Hot water temperature was measured at 115.1 degrees Fahrenheit. Bathroom #4.5 is only for staff used, this is located beside the office. There was enough clean linen available in the cabinets in the hallway.

Common Areas: LPAs toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Fireplace is close, block-off, and non-operational. Residents dining table fits enough for eight (8). LPAs observed common areas to be very clean and tidy. LPAs observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPAs obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does have a swimming pool or body of water. The garage attached and is used for group room.

Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked cabinet in the hallway that is located by the entrance.

Staff Files: LPAs also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is beside the living room. Records were checked for expired or missing certificates and clearances: LPAs conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, and HIV/AIDS and TB training.
Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MONTARE AT THE LAKE	FACILITY NUMBER: 197610020
	VISIT DATE: 03/28/2024

NARRATIVE

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Medications are in a centrally stored and locked medication room in the hallway, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: LPAs reviewed client’s files for current records. Planned activities are offered.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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