197610151-9-16-2023-31-AS-MCAA-CVQU7P-20230916152015

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610151
Report Date: 09/16/2023
Date Signed: 09/16/2023 03:20:45 PM

Document Has Been Signed on 09/16/2023 03:20 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:	AEGIS LIVING GRANADA HILLS		FACILITY NUMBER:	197610151
ADMINISTRATOR:	MATTHEW LA VINE		FACILITY TYPE:	740
ADDRESS:	10801 LINDLEY AVE		TELEPHONE:	(818) 363-3373
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	100	CENSUS: 85	DATE:	09/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Matthew La Vine, Portia Obina, Kimberly Martinez		TIME COMPLETED:	03:30 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 Analysts (LPAs) Gary Tan and Michael Cava conducted an Annual Required visit and inspection of the facility. LPAs met with staff, Portia Obina and Kimberly Martinez, and explained the reason for the visit. The administrator, Matthew La Vine, joined shortly after. At approximately 9:00am, with the assistance of staff, a tour of the physical plant was made. Facility is fire cleared for one hundred (100) non-ambulatory residents, of which ten (10) may be bedridden. Hospice waiver for ten (10) residents. Delayed egress is approved for Dementia Unit (Italy & France). There are currently five (5) residents receiving hospice care services and one (1) bedridden resident. Required postings were observed in the entry area. The facility's smoke alarms are hard wired as back up and tests are done in house on a monthly basis. Fire drill last conducted August 16, 2023. The fire extinguishers throughout the facility hallways are on all three (3) floors, all extinguishers were last serviced on June 21, 2023 Kitchen: The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperatures. There was a sufficient amount of perishable and non-perishable food at the facility and properly stored. Residents do not have access to the kitchen; dangerous items are properly stored and inaccessible to residents. The facility menu appears to meet the daily dietary needs of the residents. There were no pesticides or poisons observed near any food areas. Bedrooms: 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 and grab bars and nonskid surfaces in the bathrooms. Bathrooms: Resident bathrooms were properly supplied and had functional fixtures. Hot water temperature in random resident bathrooms were checked and measured a range of 105.4°F to 115.8°F and within the required range.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

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: AEGIS LIVING GRANADA HILLS	FACILITY NUMBER: 197610151
	VISIT DATE: 09/16/2023

NARRATIVE

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Common Areas: Common areas, including the activity rooms, movie theater, dining rooms, pool hall and library appeared clean and were properly furnished.

Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. The patios and balconies have proper furnishings.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: The medications were locked in the medication carts, properly labeled and stored. Medication documentation and implementation appeared to be complete. There is a First aid kit on each medication cart stored/parked in the medication room located in the second floor.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of this Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2023

LIC809 (FAS) - (06/04)

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