197610145-4-5-2021-31-AS-JGTN-BZPKP5-20210402080411

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610145
Report Date: 04/01/2021
Date Signed: 04/05/2021 07:20:04 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:	AARON'S CARE VILLA		FACILITY NUMBER:	197610145
ADMINISTRATOR:	SALUNGA, ALBERT		FACILITY TYPE:	740
ADDRESS:	11328 WOODLEY AVE		TELEPHONE:	(747) 237-0417
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 5	DATE:	04/01/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:02 PM
MET WITH:	Albert Salunga - Administrator		TIME COMPLETED:	04:00 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 (LPA) Gary Tan conducted an announced virtual Pre Licensing tele visit to this facility and met with applicant representatives Myline Olivas and Albert Salunga. The applicant is "Bridge for Seniors Corp". Fire Clearance dated 01/04/2021 was received for six (6) non-ambulatory residents, one (1) of which may be bedridden on room #5. Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following: The facility dual smoke/carbon monoxide alarm system is hard wired and interconnected. The fire extinguisher is located in the kitchen and was observed to be fully charged and last inspected on 09/22/2020. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested and observed to be operational. Hot water was tested in the common bathroom and measured at 112.0°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are five (5) resident bedrooms, four (4) private and one (1) one shared room. Resident bedrooms were observed to be appropriately furnished. There is an additional bedroom designated for staff use only. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records is stored in a cabinet in the kitchen area. Medications are stored in a locked cabinet also in the kitchen area. The first aid kit is readily available. There are two (2) bathrooms in the facility. All are common bathroom and have non-skid mat and appropriate grab bars installed. (continued on LIC 809-C)

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

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: AARON'S CARE VILLA	FACILITY NUMBER: 197610145
	VISIT DATE: 04/01/2021

NARRATIVE

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(continued from LIC 809)

The kitchen knives are stored in a locked drawer in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet under the kitchen sink. Laundry detergents, cleaning supplies and other toxins are stored in the locked cabinet in the laundry area. The laundry area is located outside near the patio in the backyard. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. There is no garage at the facility, only driveway. There is no body of water in the facility. There is a shed in the backyard being used as storage.

Component III is conducted with the administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

A telephonic exit interview was conducted with Licensee Representative Albert Salunga and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 04/01/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/01/2021

LIC809 (FAS) - (06/04)

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