197610272-10-22-2023-31-AS-JGTN-CWUV6T-20231022161003

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610272
Report Date: 10/22/2023
Date Signed: 10/22/2023 04:10:45 PM

Document Has Been Signed on 10/22/2023 04:10 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TOPANGA GARDENS RESIDENTIAL HOME CARE		FACILITY NUMBER:	197610272
ADMINISTRATOR:	ILLENBERGER, JEFFREY MICHA		FACILITY TYPE:	740
ADDRESS:	21709 RODAX ST		TELEPHONE:	(818) 325-6870
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91304
CAPACITY:	1	CENSUS: 1	DATE:	10/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:59 PM
MET WITH:	Michael Illenberger - Administrator		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 (LPA) Gary Tan, initially met with staff Macayle Illenberger for a One (1) Year Required visit for this facility. Administrator Michael Illenberger arrived a few minutes later. LPA explained the reason for the visit. There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. The facility had submitted and approved Mitigation plan. Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the back yard. The facility has sufficient stock of PPE in the storage room. A tour of the physical plant was conducted with the administrator at 2:15 PM. The facility is a single storey building with four (4) bedrooms and two (2) bathrooms currently occupying one (1) resident. Three (3) bedrooms and one (1) bathroom is designated for staff use. The facility is initially fire cleared for six (6) non-ambulatory residents, one (1) of which maybe bedridden. Hospice waiver for two (2) residents. Physical environment was checked for cleanliness and condition. Walls, windows, ceilings, floors and floor coverings, and doors were checked, the following was noted: Living and dining room furniture were also checked. The living room is neat and clean along with dining The facility maintains a comfortable temperature at 75°F. The smoke and carbon monoxide detectors are hardwired and inter connected and observed to be operational. The fire extinguisher was observed to filled and current..

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TOPANGA GARDENS RESIDENTIAL HOME CARE	FACILITY NUMBER: 197610272
	VISIT DATE: 10/22/2023

NARRATIVE

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The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The front and backyard passageways were clear of any obstruction. There is no body of water in the facility. The garage was converted to a two (2) bedrooms additional dwelling unit (ADU). There are two (2) sheds at the backyard being used as a storage for old equipment and other supplies. The laundry area is located inside the ADU and observed to be locked and inaccessible to the resident.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Cleaning supplies including detergents and pesticides and other toxins are stored in the cabinet under the sink. Knives and sharps are observed to be kept in a locked drawer in the kitchen.

The Clients' rooms is adequately furnished with appropriate furniture and lighting system. Clients have sufficient amount of personal hygiene product which is provided by the licensee.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars for each toilet, bathtub and shower. The hot water temperature measured at 117.8°F. Towels and washcloths are not shared. There is enough clean linen available in stock at the linen cabinet.

Medications: LPA observed the medication cabinet to be locked and inaccessible to residents. Medications are listed on the centrally stored medication and destruction record. First aid kit has complete tools and supplies.

Client records: Client record was reviewed. Client record appeared to be complete and updated. Staff records: LPA conducted a complete file review of staff record. Staff record appear to be complete and updated. Disaster drill was last conducted on 10/12/2023. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Jose Gary Tan	TELEPHONE: (323) 213-1149
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

LIC809 (FAS) - (06/04)

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