197610195-10-1-2024-31-AS-GSAO-D9MS8C-20241001133856

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610195
Report Date: 10/01/2024
Date Signed: 10/01/2024 01:39:16 PM

Document Has Been Signed on 10/01/2024 01:39 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.RO, 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: 6	DATE:	10/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Nestor Tumaliuan		TIME COMPLETED:	01:45 PM

NARRATIVE

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On 10/01/24 at 9:25 AM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with administrator Nestor Tumaliuan and disclosed the purpose of the visit.

LPA asked for the census, resident, and staff rosters.

A physical tour was conducted at 11:15 AM and observed the following:

The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The fire extinguisher is located against the wall on your left-hand side towards the staff room and garage area. It is fully charged. The expiration date is 11/2024. There is a telephone line on the counter in the kitchen. There is extra, food in the kitchen pantries. The medications are locked and inaccessible to the residents in one (1) of the top cabinets on your right-hand side. The knives are at the bottom of the sink on your left-side of one of the cabinets locked and inaccessible to the residents. The chemicals are on your right-hand side of the kitchen under the sink also locked and inaccessible to the residents. The first aid kit is in a cabinet area on your right side of the kitchen entrance.

Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. The facility does have a signal system. The facility does not have a pool/body of water.

The garage is attached to the house and can be accessed from the kitchen area. The garage has extra water, incontinence, and ensure for the residents. The washer and dryer are located in this area.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: JRBELLA HOME FOR THE ELDERLY	FACILITY NUMBER: 197610195
	VISIT DATE: 10/01/2024

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Bedrooms: There are seven (7) bedrooms and four (4) bathrooms. There are six (6) of the bedrooms for residents and one (1) for staff. One (1) of the bedrooms has a private bathroom. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 110–115-degree Fahrenheit.

The dining/living room area has enough seating for the residents and the staff. There is a large television with cable and internet access. There is also a fireplace that is covered, inaccessible to the residents.

There are cabinets in the hallway that have extra linen and incontinence supplies. The house temperature is at 76-degree Fahrenheit.

The smoke detectors are located throughout the facility and are operable. There is one (1) carbon monoxide in the kitchen area. There are fire sprinklers throughout the house. There is another fire extinguisher at the entrance of the facility.

Administrative: There is an annual fee of $495.00 due in November. At the entrance of the facility on your right-hand side there is a YES sign, facility sketch, House Rules, Disaster Plan, Covid signs, Personal Rights, Medication Policy, Fire Safety Inspection, Rights of Resident Council, Personal Property Procedure, Theft and Loss Prevention Policy. The surety bond is current and expires 12/2024.

An exit interview was conducted, no citations were issued, and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 10/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024

LIC809 (FAS) - (06/04)

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