197610191-9-23-2023-31-AS-JGTN-CVXTPK-20230923145429

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610191
Report Date: 09/23/2023
Date Signed: 09/23/2023 02:55:13 PM

Document Has Been Signed on 09/23/2023 02:55 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	GARDENS AT NORTHRIDGE, THE		FACILITY NUMBER:	197610191
ADMINISTRATOR:	GENA GRUNDEIS		FACILITY TYPE:	741
ADDRESS:	17650 WEST DEVONSHIRE STREET		TELEPHONE:	(818) 886-1616
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	135	CENSUS: 82	DATE:	09/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:31 AM
MET WITH:	Carmy Jerome - Executive Director		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	Licensing Program Analysts (LPAs) Gary Tan and Michael Cava conducted an unannounced Required One (1) year inspection to this facility. LPAs initially met with Maintenance Director Julio Lara and explained the purpose of the visit. Executive Director Carmy Jerome arrived shortly. At 9:20 AM, with the assistance of the Maintenance Director Julio Lara, LPAs conducted a tour of the facility inside and out. There is one (1) entrance being utilized at the facility, the main entrance at the front of the main building. There are required posters posted at the entrance doors. Screening area is located in the reception area. Hand sanitizer and masks are available. The facility had submitted and approved Mitigation Plan and Infection Control Plan. Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the entrance door. Hand washing, coughing etiquette, physical distancing and other necessary signage were posted in the bathroom and all over the facility. The facility has a designated visitor's area in the main lobby of the building. The facility has a sufficient stock of PPE in the storage room. The facility consists of one continuous two (2) storey building. The Memory Care unit has twenty four (24) rooms located on the ground floor and the rest are assisted living units with a total of one hundred fifteen (115) units. The facility is fire cleared for One hundred thirty five (135) non-ambulatory residents, of which, ten (10) maybe bedridden. The facility has a hospice waiver for fifteen (15) residents. (continued to LIC 809-C)

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: GARDENS AT NORTHRIDGE, THE	FACILITY NUMBER: 197610191
	VISIT DATE: 09/23/2023

NARRATIVE

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(continued from LIC 809)

The common areas such as the living room, dining room, library and a beauty salon on the first and second floor were clean, appropriately furnished and in proper order. Other common areas such as the private dining room, theater and other activity area were also observed to be appropriately furnished, clean and in proper order. Multiple activity rooms and medication rooms on both floors were also inspected and observed to be clean and in proper order. The Kitchen was observed to be clean and have functioning appliances and fixtures. There are laundry rooms on both first and second floors to serve residents, both were observed to be locked during visit.

The facility maintains a comfortable temperature at 75°F. The facility's smoke alarms are hard wired and interconnected and back up and tests are done in house on a quarterly basis, the last test was done on 06/28/23. The facility is equipped with sprinkler system which was last tested on 06/12/23. Fire protection equipment performance report was last done on 06/16/23 valid until 04/23/25. Fire extinguishers are located all throughout the facility and were last serviced on 05/11/23. Fire Drill was last conducted on 06/07/23.

Personal accommodation in resident bedrooms and bathrooms were observed for safety, privacy, and comfort. Random resident rooms were inspected and observed with all required furnishings, working signal system, grab bars and nonskid surfaces in the bathrooms. Hot water temperature in random resident bathrooms were checked and measured at a range of 107.2°F to 118.9°F. Common shower rooms on Memory care were also inspected and observed to be clean and hot water temperature was measured at 107.9°F

At 1:30 PM, LPA reviewed records of five (5) random residents and seven (7) staff. Resident and staff records appeared to be complete and updated.

Medications were observed to be in the medication cart in the Wellness centers. Medications were locked and inaccessible to residents. There were multiple complete first aid kits both in the cart and the medication rooms.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

LIC809 (FAS) - (06/04)

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