197610253-12-8-2023-31-AS-MCAA-CYBSW5-20231208131346

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610253
Report Date: 12/08/2023
Date Signed: 12/08/2023 01:14:24 PM

Document Has Been Signed on 12/08/2023 01:14 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:	ASSURECARE HOME INC		FACILITY NUMBER:	197610253
ADMINISTRATOR:	PELEGRINO, FLORENCE C		FACILITY TYPE:	740
ADDRESS:	16729 TULSA ST		TELEPHONE:	(747) 239-3219
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 5	DATE:	12/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:01 AM
MET WITH:	Florence Pelegrino, Adele Cahayon, Frances Alave		TIME COMPLETED:	01:30 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 (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Adele Cahayon and Fraces Alave and explained the reason for the visit. The administrator, Florence Pelegrino. At 9:15am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors are dual and interconnected. The fire extinguisher is located between the entrance and kitchen. It is fully charged. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The laundry room is located adjacent to the kitchen. Detergents and cleaning supplies were observed inside the laundry room, which remains locked and inaccessible to the residents. Bedrooms: There are five (5) bedrooms, of which four (4) will be used for residents and one (1) will be a staff room. The bedrooms, in use by residents were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit. Cleaning supplies are being stored in the hallway bathroom. Common Areas: These included the living room and dining area. The common areas were properly furnished. The floors were clean and had no damage or cracks. Exit/entrance and passageways were clear of obstruction. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASSURECARE HOME INC	FACILITY NUMBER: 197610253
	VISIT DATE: 12/08/2023

NARRATIVE

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Surrounding Grounds: Pathways in the front and backyards were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure compliance with licensing forms.

Medications: Medications are are stored locked in one of the kitchen cabinets. Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 12/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/08/2023

LIC809 (FAS) - (06/04)

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