197610252-3-27-2024-31-AS-LNCA-D3S44W-20240327184659

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610252
Report Date: 03/27/2024
Date Signed: 03/27/2024 06:47:10 PM

Document Has Been Signed on 03/27/2024 06:47 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:	FORBES HOME		FACILITY NUMBER:	197610252
ADMINISTRATOR:	ANDRES, CHARMILEY E.		FACILITY TYPE:	735
ADDRESS:	9608 FORBES AVE.		TELEPHONE:	(626) 926-7186
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91343
CAPACITY: 4		CENSUS: 3	DATE:	03/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Lora May Pana- Head Staff		TIME COMPLETED:	04:00 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 Analyst (LPAs) Leslie Ngo-Castaneda and Liezl De La Cerra conducted an annual required visit and inspection of the facility. LPAs met with staff Jay Inciong met and explained the reason for the visit. At 12:15 PM Lora May Pana arrived who is the head staff met with LPAs and was explained the reason for the visit as well. At 1:45 PM, with the assistance of the head staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational that are located each bedroom, the hallway and kitchen. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 3/27/2024. During the visit the facility is at 75 degrees Fahrenheit. The facility is fire cleared for four (04) non-ambulatory; four (4) bedridden. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPAs found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet in the kitchen. The menu was posted for review (ARF), snacks and beverages are available for the resident in the facility when they want. Food storage and preparation areas are clean and inaccessible to pests. Garbage cans have tight fitting covers. Cleaning supplies, pesticides or toxic cleaning supplies were stored and locked away in the kitchen cabinet below the sink. Bedrooms: There were four (4) bedrooms designated for residents' use. Bedroom #1, bedroom #2 and bedroom #3, and bedroom #4 is private, but bedroom #3 has vacant for now. The bedrooms were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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: FORBES HOME	FACILITY NUMBER: 197610252
	VISIT DATE: 03/27/2024

NARRATIVE

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Bathrooms: There are three (3) bathroom designated for residents' and staff use. The bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 108.8 degrees Fahrenheit for bathroom #1 located inside bedroom #2. Bathroom #2 is beside the living room. Hot water temperature was measured at 109.3 degrees Fahrenheit. Bathroom #3 is beside the living room and is use only for staff. There was enough clean linen available in the cabinets in the hallway and residents cabinets.

Common Areas: LPAs toured all common areas of the facility. These included the living room and dining area for residents. The common areas were properly furnished. Residents dining table fits enough for six (6). LPA observed common areas to be very clean and tidy. LPAs observed the floors to be in very good condition. No obstructions and or tripping hazards throughout the facility. Furniture in common area was observed to be in good repair. There are no issues with Fire Clearance.

Infection control: Facility mitigation plan to make sure licensee was following current infection control recommendations. LPAs obtain a copy and reviewed the infection control plan during this visit.

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The facility does not have a swimming pool or body of water. The garage attached and is used for storage.

Laundry service: There is enough linen available to change weekly or more if need. Cleaning supplies are being stored in a locked storage in the laundry area and is located in the kitchen.

Staff Files: LPAs also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms. Office space is by the living room. Records were checked for expired or missing certificates and clearances: LPAs conducted a file review of staff for criminal record clearances and current First Aid. The administrator file was reviewed for current first aid, fingerprint clearance, administrator certificate, and HIV/AIDS and TB training.

Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

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: FORBES HOME	FACILITY NUMBER: 197610252
	VISIT DATE: 03/27/2024

NARRATIVE

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Medications are in a centrally stored and locked place, including over-the-counter medicines; medications are properly labeled and checked for expiration dates. Each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. Proper medication dispensing instruction are followed and checked for contamination. First-aid has all proper items and is current.

Resident records were reviewed for requirements and legibility: LPAs reviewed client’s files for current IPP’s and surety bonds (LIC 402) a copy was handed to LPAs. Planned activities are offered. LPAs reviewed two (2) out of the three (3) residents funds and observed receipts and funds balanced. The facility is missing one (1) out of three (3) admission agreement that was not sent from Regional Center. Therefore, type V (technical violation) has been issued to administration for R2 has incomplete files.

Facility is within CA code of Regulations Title 22 or Health and Safety Code. No deficiencies were found, exit interview conducted, copy of report has been issued and discussed.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 03/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/27/2024

LIC809 (FAS) - (06/04)

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