197610188-9-6-2022-31-AS-TSMH-CHZUGF-20220906153415

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610188
Report Date: 09/06/2022
Date Signed: 09/06/2022 03:34:21 PM

Document Has Been Signed on 09/06/2022 03:34 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:	ADVANCED HOME CARE SENIOR LIVING 2 LLC		FACILITY NUMBER:	197610188
ADMINISTRATOR:	SANTOS, CATHERINE		FACILITY TYPE:	740
ADDRESS:	10109 GLADBECK AVENUE		TELEPHONE:	(818) 448-6836
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY:	6	CENSUS: 5	DATE:	09/06/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:35 PM
MET WITH:			TIME COMPLETED:	03:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tihesha “Lynn” Smith conducted an unannounced Annual Required infection Control visit to this facility at 1:35 pm and observed COVID signs on the front door. LPA Smiths’ temperature taken upon entry and Covid symptoms questions asked by caregiver Khryzel Capitanio. LPA informed staff the purpose of this visit. The administrator was called and arrived at 2:15 pm.

LPA conducted a tour of the physical plant at 2:15 pm to ensure there are no health and safety hazards and facility staff are following Title 22 Regulations and the following was noted:

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.

Facility has five (5) bedrooms for clients: four (4) private bedrooms and one (1) shared bedroom. There are two (2) bathrooms: one (1) located in hallway and one (1) in bedroom #4. There is no body water in the facility.

Kitchen area was observed to be clean and sanitary. LPA reviewed the food service area, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the five (5) clients currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed with juice. Refrigerator in garage stocked with excess vegetables and meats. Sharps observed to be locked in bottom cabinet in kitchen and inaccessible to clients.
Living and dining room furniture were also checked for functionality (wear and tear). Furniture was observed to be in good condition and adequate seating for clients.

(Cont. to 809C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

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: ADVANCED HOME CARE SENIOR LIVING 2 LLC	FACILITY NUMBER: 197610188
	VISIT DATE: 09/06/2022

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(Cont. from 809)

Bedrooms were toured and observed to be clean and properly furnished. Linen storage was also checked and observed to have ample supply of clean linen and towels in bedrooms and in hallway closet and cabinets. Bathrooms were observed to be clean and sanitary with necessary supplies. Hot water temperature for bathrooms: 116.8 and 118.4 degrees Fahrenheit.

Temperature of facility wall thermostat is observed and set to 75 degrees Fahrenheit.

Laundry area is located in garage and appliances observed to be in good repair.
Medications are located in kitchen locked in separate metal file cabinet. A locked mini fridge in garage holds additional medications. Both medication storages were observed to be inaccessible to clients. First aid kit located in kitchen bottom cabinet observed to be fully stocked.
Smoke alarms and carbon monoxide detectors were present and function properly. The fire extinguisher is located in kitchen next to first aid cabinet and observed to be charged.

Garage/Office used also used to store sufficient supply of PPEs, supplies, and equipment. All the toxins, cleaning solutions and disinfectants also stored in garage in a locked cabinet observed to be inaccessible to clients.

There is a covered patio with three (3) small patio tables with chairs for clients use. All observed to be clean and furnished with adequate seating. The grounds entry/exits area were clean and free of obstruction. LPA obtained a copy of infection control plan.

There was no immediate health and safety hazard observed during the day of inspection. There are no deficiencies to report.

Exit interview conducted and a copy of this report emailed.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 09/06/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/06/2022

LIC809 (FAS) - (06/04)

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