197610195-10-21-2021-31-AS-JMAZ-C7ZQ9J-20211021115826

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610195
Report Date: 10/21/2021
Date Signed: 10/21/2021 11:58:54 AM

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:	JRBELLA HOME FOR THE ELDERLY		FACILITY NUMBER:	197610195
ADMINISTRATOR:	TUMALIUAN, NESTOR		FACILITY TYPE:	740
ADDRESS:	17100 CALAHAN STREET		TELEPHONE:	(818) 524-8613
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 2	DATE:	10/21/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Adiminstrator- Nestor Tumaliuan		TIME COMPLETED:	12:15 PM

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Licensing Program Analyst (LPA) Joscelyn Martinez and Melissa Ruiz conducted an announced Pre-Licensing visit to the facility and met with administrator Nestor Tumaliuan. This is a change of ownership application from (LIC 197600281) to (LIC 197610195). The applicant is “JRBELLA Home for the Elderly”. LPAs conducted an entrance interview with the administrator. Application was received for a total of six (6) total residents of which zero (0) are non-ambulatory and six (6) are bedridden. At the time of the visit LPAs observed and assessed 2 residents present in the facility. All residents appear to be clean and groomed. Fire clearance dated 07/28/2021 was received for six (6) bedridden residents. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulation, Title 22, Division 6. The facility is a single-story building. Today’s site visit consisted of LPAs touring the physical plant inside and outside and observed the following:

The facility has a total of 6 bedrooms, 5 of which are designated for resident and 1 for staff use. Resident bedrooms were observed to be appropriately furnished. There is a total of 3 bathrooms in the facility in which 1 is designated for staff use and were observed to have non-skid mats and appropriate grab bars installed.

The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. Resident and staff records will be stored in a cabinet located in the dining area. The fire extinguisher is located near the front door and kitchen area with a service date of 12/ 01/21. Dual smoke detectors and carbon monoxide detectors were located throughout the facility, and at 10:47 AM were tested and observed to be operational. At 10:55 the hot water was tested in the common bathrooms and measured between 199.7-120 degrees Fahrenheit. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted by the entrance wall with other posting requirements. Medications are stored in a locked cabinet in the kitchen area. The first aid kit is readily available.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

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: JRBELLA HOME FOR THE ELDERLY	FACILITY NUMBER: 197610195
	VISIT DATE: 10/21/2021

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Facility appears to be clean, in good repair and kept at a comfortable temperature of 73 degrees Fahrenheit. Appliances in the kitchen appeared to be functional. There is a separate laundry room that remains locked and leads to the attached garage that is being used for storage. Component III was conducted with the administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and be notified by the CAB Analyst when your license has been approved.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Joscelyn Martinez	TELEPHONE: (818) 383-6108
LICENSING EVALUATOR SIGNATURE:	DATE: 10/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2021

LIC809 (FAS) - (06/04)

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