197610079-10-20-2021-31-AS-APAA-C7YR4E-20211020124125

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610079
Report Date: 10/20/2021
Date Signed: 10/20/2021 12:43:17 PM

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:	CANYON VIEW RESIDENTIAL CARE FACILITY, INC.		FACILITY NUMBER:	197610079
ADMINISTRATOR:	VENTURA, CHERYL M.		FACILITY TYPE:	740
ADDRESS:	26881 CUATRO MILPAS STREET		TELEPHONE:	(562) 881-4998
CITY:	VALENCIA	STATE: CA	ZIP CODE:	91354
CAPACITY:	6	CENSUS: 5	DATE:	10/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:20 AM
MET WITH:	Maricar Serrano, Administrator		TIME COMPLETED:	01:00 PM

NARRATIVE

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At 11:20am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by staff, Purificacion Guerina, who granted access to the facility. At approximately, 11:25am physical tour was conducted with the staff and shortly after the Administrator, Maricar Serrano, arrived. LPA observed the following:

Infection control: LPA reviewed the facility mitigation plan (approved on 03/14/2021) to make sure licensee was following current infection control recommendations. Upon arrival, LPA was screened and asked to sign-in the visitors’ log. In addition, LPA was asked all infection control questions. Proper signage was observed inside along the hallway and in the restrooms. Hand sanitizer was also observed. Administrator stated they have sufficient PPE supplies for residents and staff. LPA observed all trash can throughout the facility have fitted lids.

Kitchen: At approximately, 11:25am LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. Appliances in the kitchen appeared to be functional. All knives and sharp objects were locked and inaccessible to residents in care.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 11:53am they were tested and observed to be operational.

Bedrooms: There are four (4) out of five (5) bedrooms designated for residents' use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms are in a good repair, were tested and observed to be operational. Facility is licensed for six (6) non-ambulatory, of which six (6) may be bedridden and six (6) hospice residents.

Bathrooms: At 11:40am 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 111.7°F.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

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: CANYON VIEW RESIDENTIAL CARE FACILITY, INC.	FACILITY NUMBER: 197610079
	VISIT DATE: 10/20/2021

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LPA observed all bathrooms with an appropriate grab bars and had non-skid mats. LPA observed appropriate hand washing signs posted in each bathroom

Common Areas: The facility maintains a comfortable temperature at 78°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. There is a fire extinguisher in the kitchen area and was last serviced on 09/03/2021.

Outside areas: At approximately, 11:55am LPA toured the outside area of the facility. The backyard is fenced and LPA observed shaded sitting area with an appropriate outdoor furniture for residents to conduct outdoor activities. There are no bodies of water.

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

Medications: At approximately, 11:27am LPA observed medications are centrally stored and locked in the cabinet, in a kitchen area, and inaccessible to residents in care.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500. Annual fees are current.

Exit interview conducted and copy of this report was provided to the Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2021

LIC809 (FAS) - (06/04)

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