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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610055
Report Date: 12/07/2020
Date Signed: 12/10/2020 08:14:08 AM

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 SPLENDOR HOMEFACILITY NUMBER:
197610055
ADMINISTRATOR:JENG, CHRISFACILITY TYPE:
740
ADDRESS:500 GEORGIAN ROADTELEPHONE:
(818) 434-3237
CITY:LA CANADASTATE: CAZIP CODE:
91011
CAPACITY:6CENSUS: 0DATE:
12/07/2020
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Chris Jeng, AdministratorTIME COMPLETED:
12:17 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an announced Pre-Licensing visit to this facility and met with Chris Yeng, Administrator. Facility is fire cleared for three ambulatory, two non-ambulatory and one bedridden. Currently there are no residents in care. Due to the situation surrounding the Corona Virus Disease 2019 (COVID-19) and to implement mitigation measures, today's visit was conducted virtually with the use of face time with the applicant. Visit was conducted on 12/07/2020. Component three was also conducted and completed on 12/07/2020.

LPA was given a tour of the physical plant. Facility has seven bedrooms. Two bedrooms are designated for staff. Four bedrooms are private bedrooms while one bedroom is a shared room. LPA observed all bedrooms to be appropriately furnished. There are five bathrooms. One bathroom is designated for staff. All resident bathrooms have grab bars and non skid mats. Hot water was observed by LPA and administrator to be at 120 degrees by using a thermometer. The facility smoke alarm system and carbon monoxide are operable. LPA checked the kitchen area for the ability to prepare and store food. LPA observed knives, sharp objects, and cleaning supplies to be locked away and inaccessible. Medications will be locked in kitchen cabinets. Emergency telephone numbers are on the kitchen wall along with other required posters. There is a working telephone on the premises.

LPA toured all common areas. LPA observed the home to be clean and furniture to be in good condition. In the back of the home is a swimming pool that has a locked gate and is inaccessible to residents.

A telephonic exit interview was conducted and a hard copy of the report was provided via email for signature. LPA will notify Centralized Application Unit regarding component three being complete along with the pre-licensing visit having been conducted.


SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2020
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2020
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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