197610278-8-25-2022-31-AS-NRED-CHMQWT-20220825123229

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610278
Report Date: 08/25/2022
Date Signed: 08/25/2022 12:33:01 PM

Document Has Been Signed on 08/25/2022 12:33 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:	CENTRAL STAR OLIVE VIEW UCLA CRT		FACILITY NUMBER:	197610278
ADMINISTRATOR:	MARSH, KASEY		FACILITY TYPE:	772
ADDRESS:	14129 BUCHER AVENUE		TELEPHONE:	(818) 290-5308
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY: 16		CENSUS: 0	DATE:	08/25/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Kasey Marsh		TIME COMPLETED:	12:40 PM

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At 9:40 a.m. on 08/25/2022, Licensing Program Analyst (LPA) Nicholas Reed and Licensing Program Manager (LPM) Cassandra Harris conducted an announced prelicensing visit. LPA and LPM met with Administrator and disclosed the reason for the visit. LPA, LPM, and Administrator toured the facility inside and out.

It is a two story facility with 9 bedrooms, 9 bathrooms, pantries, common areas, lactation room, medication room and outdoor areas. It has an approved fire clearance for 16 residents, of which 2 may be non-ambulatory. The facility uses surveillance cameras inside.

LPA was screened for infectious disease upon entry. The screening station contained a digital thermometer, visitor log. The visitor log tracked contact information, temperature, and symptoms. LPA noted the visitor log should also document vaccination status. Postings included grievance procedures, personal rights, non-discrimination notice, confidential complaint contacts, emergency contacts, ombudsman contacts. activity schedule, and facility menu.

Walls, floors, ceilings, windows, and blinds were clean and in good repair. At 9:45 a.m. LPA measured the room temperature to be 73 degrees Fahrenheit. Past the screening station were an intake office and a mud room for sanitation. The mud room contained a shower which provided hot water. LPA measured the water to be 105.7 degrees Fahrenheit at 9:58 p.m. The mud room also contained a Zapp machine for sanitation. Janitor closets on the first and second floor were locked. Cleaning supplies were locked in the linen closet with extra linens and hygiene supplies. The facility has sufficient emergency water supplies in the stairwells. Emergency food supplies were located in the first floor pantry. The pantry contained sufficient supplies of perishable and non-perishable food. The pantry also contained two refrigerators, two freezers, cooking tops, and a retherm unit. At 10:17 a.m. LPA measured a refrigerator and freezer temperatures to be 31 degrees Fahrenheit and -5 degrees Fahrenheit, respectively. Sharps were locked in a drawer by the sink. The dining room outside of the pantry contained utensils, a sink, storage, and two computers.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

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: CENTRAL STAR OLIVE VIEW UCLA CRT	FACILITY NUMBER: 197610278
	VISIT DATE: 08/25/2022

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The facility has 9 bedrooms in total. 2 bedrooms on the first floor are private. 2 on the first floor and 5 on the second floor are shared bedrooms. Bedrooms had double doors which could be opened from the outside in case of emergency. All bedrooms contained a chair, nightstand, emergency lighting, facility sketch with evacuation routes clearly labelled, storage, and beds with adequate beddings. All furnishings were clean and in good condition. Shared rooms contained beds which were at least 6 feet apart for social distance. All beds and bathrooms contained a pull cord for the call system. At 10:02 a.m. LPA tested the pull cords in Room 117. The light above the doorway signaled, and office computers were alerted. Administrator noted the staff will perform hourly checks on clients. Laundry machines are located on the first floor with locked cabinets for detergents. The facility has 9 bathrooms. All bathrooms contained liquid soap, paper towels, and grab bars near the shower. At approximately 11:30 a.m. LPA measured the water temperature in a first floor bathroom to be 105.0 degrees Fahrenheit. Staff offices, medication room, lactation room, and bedrooms were on the second floor. The medication room contained a refrigerator and a locked medication cabinet with extra locked storage. The facility has two complete first aid kits. At 10:32 a.m. LPA observed a fully-charged fire extinguisher on the second floor which was last serviced on 07/28/2022. All emergency exit paths were free from obstructions. Exit doors were unlocked. Emergency Disaster Plan posted. At 10:59 a.m. staff tested the smoke detector to be operational. The facility has sprinklers installed, and all smoke detectors are hardwired. The outdoor area was sanitary and free of hazards. Patio furniture was in good repair was covered by an umbrella.

At approximately 10:50 a.m. LPM confirmed the facility vehicle is operable and in good condition. At 11:50 a.m. Administrator provided proof of insurance and registration.

At 12:05 p.m. Administrator and LPA reviewed Component III.

At 12:25 p.m. LPA tested the carbon monoxide detector in the pantry to be functional.

During today's inspection, the facility is in compliance with regulations.

Exit interview conducted. Copy of report issued.

Pre-Licensing is complete and this facility has no deficiencies.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 08/25/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/25/2022

LIC809 (FAS) - (06/04)

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