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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610258
Report Date: 06/10/2022
Date Signed: 06/10/2022 05:35:32 PM

Document Has Been Signed on 06/10/2022 05:35 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 ELDERLYFACILITY NUMBER:
197610258
ADMINISTRATOR:GACAYAN, CAMERONFACILITY TYPE:
740
ADDRESS:19825 LEADWELL ST.TELEPHONE:
(818) 718-2750
CITY:CANOGA PARKSTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 3DATE:
06/10/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Cameron Gacayan, Francisco FabrigasTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Michael Cava conducted an announced Pre Licensing visit to this facility and met with applicant representatives Francisco Fabrigas and Cameron Gacayan. This is a Change in Ownership application The applicant is "Chelsea LLC." Fire Clearance dated 04/11/22 was received for five (5) bedridden/non-ambulatory residents, and one (1) Ambulatory.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility has dual smoke/carbon monoxide alarm system. It is hard wired and interconnected. The fire extinguisher is located in the kitchen and was observed to be fully charged and last inspected on 08/16/2021. Dual Smoke and Carbon Monoxide detectors were observed all over the facility. Hot water was tested in the common bathroom and measured at 108 °F. There is a functioning telephone on the premises. There are five (5) resident bedrooms. Four (4) rooms are private, and one room is shared. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished and lighting was adequate. The living room has a television and comfortable furniture. Resident and staff records will be stored in a locked cabinet located near the living room. Medications are stored and locked in the kitchen. The first aid kit was observed complete and readily available. There are two (2) bathrooms in the facility. Both common bathrooms have non-skid mats and appropriate grab bars installed.

(continued on LIC 809-C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2022
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: 06/10/2022
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The kitchen knives will be stored in a locked cabinet in the kitchen. Kitchen cleaning supplies will be stored in a locked cabinet in below the sink. Laundry area is located adjacent to the kitchen. Cleaning supplies and other toxins will be stored in a locked cabinet in the bathroom. The garage has an access from inside the house and was observed to be locked and inaccessible. The garage will also be used as staff room, storage for emergency food supplies, tools and other toxins. The necessary precautions have been made to the facility to safely house the residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a sitting area in the backyard for residents to conduct outdoor activities. The backyard is fenced. There is no body of water in the facility.

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

Exit interview conducted and copy of this report issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2022
LIC809 (FAS) - (06/04)
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