197610174-12-22-2022-31-AS-JGTN-CHVR2V-20220902123858

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610174
Report Date: 09/02/2022
Date Signed: 12/22/2022 04:12:28 PM

Document Has Been Signed on 12/22/2022 04:12 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:	RIDGEVIEW HOME CARE CENTER		FACILITY NUMBER:	197610174
ADMINISTRATOR:	MANICDAO, MARY PRINCESS F.		FACILITY TYPE:	740
ADDRESS:	2327 RIDGEVIEW AVE		TELEPHONE:	(323) 308-8002
CITY:	LOS ANGELES	STATE: CA	ZIP CODE:	90041
CAPACITY:	6	CENSUS: 5	DATE:	09/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Mary Lou Miranda - Co-Administrator		TIME COMPLETED:	12:30 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	A Required One (1) year - Infection Control visit was conducted today by Licensing Program Analyst (LPA) Gary Tan. LPA met with Co-Administrator Mary Lou Miranda. Purpose of visit was stated. LPA observed that all five (5) residents were at the facility during visit. A tour of the physical plant was conducted at 9:25 AM 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 mask and must be screened. Screening area is located around 10' upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened by the staff upon entry. All staff were observed to be wearing mask. There is a hand sanitizer all over the facility The facility had submitted and 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 in the bathroom and all over the facility. All trash cans were observed to be with cover. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room. The facility has six (6) bedrooms and four (4) bathrooms currently occupying six (6) residents on one (1) shared bedrooms and four (4) private rooms. One (1) bedroom designated for staff use. The facility is fire cleared for six (6) bedridden residents and approved hospice waiver for two (2) 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: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

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: RIDGEVIEW HOME CARE CENTER	FACILITY NUMBER: 197610174
	VISIT DATE: 09/02/2022

NARRATIVE

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Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted:

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 78°F. Dual smoke and carbon monoxide are hardwired and inter connected and observed to be operational. The fire extinguisher was last inspected on 07/07/22. The facility is equipped with sprinkler system.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility.

The garage detached to the home and was converted to staff quarter, storage for frozen food and laundry area.
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. Cleaning supplies including detergents and pesticides and other toxins are stored in the converted garage. Dishwashing liquid, knives and sharps are kept at the cabinet below the kitchen sink and was locked and inaccessible to residents. Knives and sharps are observed to be kept in a locked drawer.

The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Clients have sufficient amounts of personal hygiene product which is provided by the licensee. Staff Rooms: Staff room was locked. No medications are observed in the staff room.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at a range of 105.8°F to 113.5°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet.

Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. First aid kit is observed to be with complete tools and supplies.

Exit interview conducted and 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: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC809 (FAS) - (06/04)

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