197610113-1-30-2024-31-AS-HRAI-CZYT5T-20240130132603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610113
Report Date: 01/30/2024
Date Signed: 01/30/2024 01:26:12 PM

Document Has Been Signed on 01/30/2024 01:26 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ORCHID FACILITY		FACILITY NUMBER:	197610113
ADMINISTRATOR:	FAHIMI, IDA		FACILITY TYPE:	740
ADDRESS:	6217 CALVIN AVE.		TELEPHONE:	(424) 224-6294
CITY:	TARZANA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 6	DATE:	01/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	IDA FAHIMI, Administrator		TIME COMPLETED:	02:00 PM

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At 09:00 AM, Licensing Program Analyst (LPA) Huma Rahimi conducted an unannounced annual visit. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

It is a two-story building with 6 bedrooms, 4 bathrooms, kitchen, garage, common areas, and outdoor areas. The second-floor stairway is locked and inaccessible to residents. It has an approved fire clearance for 6 nonambulatory residents, of which 1 may be bedridden in Bedroom #1. The facility serves residents with dementia. Approved hospice waivers for six (6). The facility uses surveillance cameras on the exterior and in common areas.

Kitchen: At approximately, 9:30 AM LPA toured the kitchen area and observed an adequate supply of perishable and non-perishable food in the kitchen. Surfaces were sanitary and appliances were functional. The stove hood was free of debris. Sharps were locked by the refrigerator, and cleaning solutions locked were locked in the laundry area which was next to the kitchen. The washer and dryer were in good repair and functional.

Bedrooms: The facility is fire cleared for six (6) nonambulatory residents. LPA observed total of six (6) private bedrooms designated for resident use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff.

Medications: At approximately, 9:48 AM LPA observed medications are centrally stored and locked in the hallway by bedroom # five (5) in a cabinet.

Bathrooms: LPA observed four (4) bathrooms and all bathrooms appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 9:55 AM, hot water temperature measured at 113.2°F. Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

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: ORCHID FACILITY	FACILITY NUMBER: 197610113
	VISIT DATE: 01/30/2024

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Common Areas: The facility maintains a comfortable temperature at 74°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility. The facility does not have any garage.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:05 AM they were tested and observed to be operational. LPA tested the dual functioning smoke and carbon monoxide detector in the living room to be operational. When tested, 4 out of 4 detectors functioned simultaneously and 2 out of 2 fire doors closed. At . 10:10 AM, LPA observed a fully charged fire extinguisher in the kitchen. It was purchased and inspected on 09/09/2023.

Outside areas: At approximately, 10:15 AM LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. All emergency exit paths were free from obstructions.

Between 10:30 AM to 12:30 PM, LPA reviewed records of six (6) clients and four (4) staff. Client and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 01/30/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/30/2024

LIC809 (FAS) - (06/04)

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