197610258-11-3-2023-31-AS-APAA-CX8R4A-20231103124112

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610258
Report Date: 11/03/2023
Date Signed: 11/03/2023 12:41:41 PM

Document Has Been Signed on 11/03/2023 12:41 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:	HOME FOR THE ELDERLY		FACILITY NUMBER:	197610258
ADMINISTRATOR:	GACAYAN, CAMERON		FACILITY TYPE:	740
ADDRESS:	19825 LEADWELL ST.		TELEPHONE:	(818) 718-2750
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91306
CAPACITY:	6	CENSUS: 5	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Francisco F Fabregas, Administrator		TIME COMPLETED:	01:10 PM

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At 10:10am Licensing Program Analyst (LPA), Angela Panushkina, conducted an unannounced annual inspection at the facility mentioned above. LPA was greeted by the Staff #1 (S1), who granted access to the facility. Administrator arrived shortly after and LPA explained the reason for the visit.

At 10:30am, LPA conducted a tour of the facility and the following was observed:

Kitchen: LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. There is a fire extinguisher in the kitchen and it was last serviced on 08/02/2023.

Medications: At approximately, 10:35am LPA observed medications are centrally stored and locked in the kitchen cabinet and inaccessible to residents in care.

The garage: Laundry was located between the kitchen and an attached garage. LPA observed all laundry detergents, chemicals and extra PPE supplies stored in the garage and kept locked and inaccessible to residents in care. Extra food storage was also observed.

Bedrooms: The facility has five (5) bedrooms designated for residents use and have sufficient lighting. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Auditory alarms were tested and observed to be operational.

Bathrooms: At 10:45am LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 106.9°F. LPA observed

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2023

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: HOME FOR THE ELDERLY	FACILITY NUMBER: 197610258
	VISIT DATE: 11/03/2023

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appropriate grab bar and non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom.

Common Areas: The facility maintains a comfortable temperature at 74°F. The living room and dining area appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. There is a fire extinguisher by the dining area observed to be operational.

Smoke detectors/carbon monoxide. Dual smoke and carbon monoxide detectors were located throughout the facility, and at 10:50am they were tested and observed to be operational.

Outside areas: At approximately, 11:00am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Administrative: LPA collected Certificate of Liability Insurance and LIC.500.

Between 11:10am to 12:30pm, LPA reviewed records of three (3) residents and two (2) staff. Resident and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance and LIC500.

No citations issued during this visit. Exit interview conducted. Copy of report emailed to Licensee.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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