197610151-5-21-2021-31-AS-JGTN-C38U2J-20210521151201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610151
Report Date: 05/21/2021
Date Signed: 05/21/2021 03:12:42 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:	AEGIS LIVING GRANADA HILLS		FACILITY NUMBER:	197610151
ADMINISTRATOR:	SHENK, LANCE		FACILITY TYPE:	740
ADDRESS:	1080 LINDLEY AVENUE		TELEPHONE:	(818) 363-3373
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	100	CENSUS: 83	DATE:	05/21/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	08:11 AM
MET WITH:	Lance Shenk - Executive Director		TIME COMPLETED:	02:00 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 pre Licensing visit today and met with Executive Director Lance Shenk. The applicant is "Lindley Ave Granada Hills LLC". Fire Clearance dated 04/30/2021 was received for one hundred (100) non-ambulatory residents, ten (10) of which may be bedridden on the first floor and four (4) delayed egress in each memory care unit and two (2) delayed egress exterior gates. 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. Physical plant inspection started at 9:03 AM. The facility is a three (3) storey building, the second and third floor are designated for Assisted Living units and first floor has two (2) wings of dementia units (Italy and France) Today's site visit consisted of LPA touring the facility inside and outside, and observed the following: Common areas, including the activity rooms, movie theater, dining rooms and library appeared clean and were properly furnished. The kitchen appeared clean and the appliances and fixtures functional. Residents do not have access to the kitchen; dangerous items are properly stored and inaccessible to residents. Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings. The medications were locked in the medication carts. Personal accommodations in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings, working signal system, grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked and measured a range of 105.4°F to 115.5°F. (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: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: AEGIS LIVING GRANADA HILLS	FACILITY NUMBER: 197610151
	VISIT DATE: 05/21/2021

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
26
27
28
29
30
31
32

(continued from LIC 809)

Fire extinguishers are located throughout the facility hallways on all three (3) floors and were last serviced on 05/20/21. There is a First aid kit on each medication cart stored/parked in the medication room located in the second floor. The facility's smoke alarms are hard wired and interconnected and back up and tests are done in house on a monthly basis

The facility is equipped with sprinkler system. Facility appears to be clean and in good repair.

There are sitting areas in the front and backyard for residents to conduct outdoor activities. The backyard is fenced. There is no body of water in the facility.

Component III was given to the Executive Director.

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.

An exit interview was conducted with Executive Director Lance Shenk and a copy of this report was issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/21/2021

LIC809 (FAS) - (06/04)

Page: 2 of 2