197610165-3-29-2022-31-AS-MCAA-CCYTGM-20220329144324

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610165
Report Date: 03/29/2022
Date Signed: 03/29/2022 02:54:05 PM

Document Has Been Signed on 03/29/2022 02:54 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:	MCNULTY VILLA		FACILITY NUMBER:	197610165
ADMINISTRATOR:	WOOD, CHERIE		FACILITY TYPE:	740
ADDRESS:	20724 MCNULTY PL.		TELEPHONE:	(818) 395-6037
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 5	DATE:	03/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Teresita Miller		TIME COMPLETED:	03:00 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	A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Michael Cava. LPA met with staff, Teresita Miller and stated the purpose of the visit. Ms. Miller called the administrator, Cherie Wood to also advise her of today's purpose. LPA observed that all five (5) residents were at the facility during the visit. The tour of the physical plant was conducted at 12:30pm and the following were noted: The main door is the only entrance being utilized for entry. There is a sign on the door that everyone entering at the facility must wear a mask and must be screened. The screening area is located near the entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened by staff upon entry. All staff were observed to be wearing a mask. The facility submitted an approved Mitigation Plan. Signs to wear a mask and other COVID 19 prevention protocol signs were posted on the walls. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted all over the facility. All trash cans were observed to be with covers. The facility has a designated visitor's area in the living room or at the backyard. The facility has a sufficient supply of PPE in the storage room. Resident rooms: The facility has a fire clearance for four (4) non-ambulatory and two (2) ambulatory only. There are four (4) Resident rooms which were observed to have appropriate lighting, furniture, bedding, and linens.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

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: MCNULTY VILLA	FACILITY NUMBER: 197610165
	VISIT DATE: 03/29/2022

NARRATIVE

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Bathrooms: LPA toured resident bathrooms and checked to make sure bathrooms were clean and in good repair. The hot water temperature measured at 112 degrees F. Towels and washcloths are not shared. Residents have sufficient amounts of supplies for personal hygiene items which is provided by the Licensee.

Common Areas: LPA toured the common areas of the facility. LPA observed common areas to be clean and furniture in good repair. The facility maintains a comfortable temperature at 74 degrees F. LPA observed a fire extinguisher maintained in the kitchen, that is fully charged. The smoke/carbon monoxide detectors are operational. There are no issues with Fire Clearance.

Outside areas: LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients.

The garage: Facility has an attached garage that is locked and inaccessible to the residents in care.

Food Inspection: LPA conducted a food inspection tour. LPA observed there to be sufficient stock of two-day perishable and seven-day non-perishables foods. Snacks and beverages are available for clients in the facility when they want. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies, pesticides or toxins were stored and locked away.

Laundry: The laundry area is located near the kitchen area. Cleaning supplies are stored and observed to be in locked cabinets. There is enough linen available to change weekly or more if need.

Pursuant to CA code of Regulations Title 22 or Health and Safety Code. No deficiencies observed during the day's visit. Exit interview conducted and a copy of this report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 03/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/29/2022

LIC809 (FAS) - (06/04)

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