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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610055
Report Date: 11/17/2022
Date Signed: 11/17/2022 05:17:06 PM


Document Has Been Signed on 11/17/2022 05:17 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 SPLENDOR HOMEFACILITY NUMBER:
197610055
ADMINISTRATOR:MARY JANE V MCLELLANDFACILITY TYPE:
740
ADDRESS:500 GEORGIAN ROADTELEPHONE:
(818) 434-3237
CITY:LA CANADASTATE: CAZIP CODE:
91011
CAPACITY:6CENSUS: 4DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
03:50 PM
MET WITH:Mary Jane McLelland, AdministratorTIME COMPLETED:
05:15 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced Required One (1) year Infection Control inspection to the facility. LPA met with Administrator Mary Jane McLelland and explained the reason for the visit.

A tour of the physical plant was conducted at 4:00pm and the following was noted:

There is only one entrance being utilized at the facility. Screening area is located immediately upon entrance. Sign in sheet and, and masks are available.

The facility had submitted and approved Mitigation Plan.

The facility has a designated visitors' area.

The facility has six (06) bedrooms and six (05) bathrooms currently occupying four (04) residents.

(continued on LIC 809-C
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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: A SPLENDOR HOME
FACILITY NUMBER: 197610055
VISIT DATE: 11/17/2022
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Living and dining room furniture were also checked. The living room is neat and clean. The facility maintains a comfortable temperature at 76 degrees. The smoke detector was observed to be operational. There is a carbon monoxide detector in the facility. Fire extinguishers are located in the kitchen and in the hallway.

There is a body of water at the facility but it is not accessible to residents since there are two locked gates at each side. There is also a shed in the backyard being used to store equipment..

Laundry area is located by the kitchen, laundry detergents, cleaning agents and other toxins are stored inside and were observed to be locked.

Knives and sharp objects were observed to be locked and inaccessible to residents.

The residents rooms are adequately furnished with appropriate furniture and lighting system.

The bathroom was checked for cleanliness and proper operation. LPAs observed the appropriate grab bars in the shower and toilet. The hot water temperature was measured at 118 degrees F. There was enough clean linen available in stock in the cabinet.

There are three ( 03) complete first aid kits and they are located in the kitchen.

Exit interview conducted. A copy of this report was issued and signature obtained.
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/17/2022
LIC809 (FAS) - (06/04)
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