197610154-5-14-2022-31-AS-JGTN-CEEQ8P-20220514115705

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610154
Report Date: 05/14/2022
Date Signed: 05/14/2022 03:38:02 PM

Document Has Been Signed on 05/14/2022 03:38 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:	A PRECIOUS CARE VILLA		FACILITY NUMBER:	197610154
ADMINISTRATOR:	DOMINGO, OLIVER		FACILITY TYPE:	740
ADDRESS:	8413 RHEA AVE		TELEPHONE:	(818) 626-9343
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 4	DATE:	05/14/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:27 AM
MET WITH:	Oliver Domingo - Administrator		TIME COMPLETED:	12:00 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 Analysts (LPA) Gary Tan initially met with staff Simon Orve for a One (1) Year Required - Infection Control visit for this facility. Staff called who called the administrator Oliver Domingo and arrived twenty (20) minutes later. LPA explained the reason for the visit. A tour of the physical plant was conducted at 9:10 AM and the following was noted: There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has five (5) bedrooms and two (2) bathrooms currently occupying four (4) residents. One (1) bedroom is designated for staff use. The facility is fire cleared for four (4) non-ambulatory residents, all of which may be bedridden and two (2) ambulatory residents only. Hospice waiver for six (6) residents (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2022

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: A PRECIOUS CARE VILLA	FACILITY NUMBER: 197610154
	VISIT DATE: 05/14/2022

NARRATIVE

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Living and dining room furniture were also checked. The living room is neat and clean along with the family room. The facility maintains a comfortable temperature at 72°F. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide installed at the facility. Fire extinguisher is located in the kitchen and observed to be full and current. The facility is equipped with fire sprinkler.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. There is no body of water in the facility.

The garage is currently being used as old equipment, tools and other supplies storage. Laundry room is located in the garage. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage. Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

Staff Rooms: Staff room was observed to be locked, located adjacent to the kitchen. No medications are observed in the staff room.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured a range of 114.4°F to 115.8°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication cabinet in the kitchen to be locked and inaccessible to residents. There is a complete first aid kit located inside the medication cabinet.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 05/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/14/2022

LIC809 (FAS) - (06/04)

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