197610279-6-28-2022-31-AS-NRED-CFTR8T-20220628124828

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610279
Report Date: 06/28/2022
Date Signed: 06/28/2022 12:49:32 PM

Document Has Been Signed on 06/28/2022 12:49 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:	INFINITY SENIOR CARE LLC		FACILITY NUMBER:	197610279
ADMINISTRATOR:	PAMINIANO, DIANA		FACILITY TYPE:	740
ADDRESS:	6930 NESTLE AVE		TELEPHONE:	(747) 895-9091
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 0	DATE:	06/28/2022
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Diana Dimalanta		TIME COMPLETED:	12:58 PM

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At 10:00 a.m. on 06/28/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an announced prelicensing visit. LPA met with Administrators Diana Dimalanta and Teresa Sta. Ines and disclosed the reason for the visit. LPA and Administrators toured the facility inside and out.

It is a single story building with 5 bedrooms, 3 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 5 may be non-ambulatory and 1 bedridden in Bedroom #5. The facility will serve residents with dementia. Approved hospice waivers for 4.

Entry: LPA observed a front yard in good condition. The door nearest the street has postings for the facility’s COVID policies and a sign directing visitors to a side door for screening. Administrator confirmed the front door will not be the main entrance. LPA observed a ramp with no hand rail. Licensee removed the ramp. LPA walked through a blue metal gate and saw the side door, which serves as the main entrance. A ramp with sturdy handrails led up to the main entrance.

Screening: LPA was screened for infectious disease upon entry. The screening station contained a visitor’s log, digital thermometer, N95 masks, and hand sanitizer. The facility’s COVID policies are posted on the door and inside. The visitor’s log tracks contact tracing information, symptoms, temperature, and vaccination status.

Kitchen: LPA observed an adequate supply of perishable and non-perishable food. At 10:14 a.m. LPA measured the refrigerator and freezer temperatures to be 40 and -1 degrees Fahrenheit, respectively. The stove hood was clean. Stove burners were operational. Sharp objects were locked near the dishwasher, and cleaning solutions were locked under the sink with magnetic locks.

Laundry: LPA observed a locked laundry room near the kitchen. A washer and dryer were in good condition. Detergent was located in cabinets above the washer and dryer.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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: INFINITY SENIOR CARE LLC	FACILITY NUMBER: 197610279
	VISIT DATE: 06/28/2022

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Common Areas: Books, television, board games, and activities were in the living room. A fireplace is located behind the television. It is non-operational with the gas turned off. The house telephone is located by the front door. Emergency numbers are posted near the phone. The facility uses 3 different ventilation units for Bedrooms #4 and #5, Bedrooms #1 #2 and #3, and the common areas. Medications and personnel records are stored in a locked cabinet near the main entrance. LPA observed postings for confidential complaints, resident rights, resident councils, non-discrimination policy, theft and loss procedure, and Administrator certificate. Walls, floors, ceilings, windows, screens, and blinds were clean and in good repair. At 10:22 a.m. LPA measured the room temperature to be 77 degrees.

Bedrooms: The facility has 5 bedrooms. 4 are private. 1 can be shared. Bedroom #5 is approved for a bedridden resident. The exit door was unlocked. The exit path was free from obstructions and sufficiently wide. The ramp and handrail leading down were secure and in good condition. Bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition.

Bathrooms: The facility has 3 bathrooms. Bedroom #4 has a private bathroom. The bathroom west of Bedroom #4 is designated for staff and visitors. All bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At 10:25 a.m. LPA measured the water temperature in Bathroom #4 to be 108.1 degrees Fahrenheit.

Safety: All emergency exit paths were free from obstructions. The metal blue gate at the front of the property is unlocked. The gate is controlled manually. Emergency Disaster Plan was posted at the main entrance. Evacuation routes are posted and clearly labelled by each bedroom. At 10:14 a.m. LPA observed a fully charged fire extinguisher in the kitchen. Administrator showed a first aid kit which was locked in the medication cabinet. The first aid kit contained an approved manual, tweezers, thermometer, scissors, bandages, and clean dressings. At 10:17 a.m. LPA tested the smoke detectors near the kitchen and in the hallway to be operational. At 10:20 a.m. LPA tested the carbon monoxide detector to be operational. 3 out of 3 auditory alarms were functional when exit doors were opened.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

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: INFINITY SENIOR CARE LLC	FACILITY NUMBER: 197610279
	VISIT DATE: 06/28/2022

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Outdoor areas: A covered patio area was located east of the main building. The patio area contained artificial grass, plants, strings of lights, and furniture in good condition. Fences are at least 5 feet along the perimeter. The rear fence is leaning. LPA discussed the fence with the Administrator. Administrator agreed to report if the fence condition gets worse. Administrator also noted the costs of repair will be split between the landlord of the property and the neighbor.

Additional Dwelling Unit: The unit located by the patio area is a staff bedroom. It contained storage items, a bathroom, and a kitchenette. The unit was locked and free of hazards.

Administrators and LPA reviewed Component III at approximately 11:40 a.m. During today's inspection, the facility is in compliance with Title 22 regulations and ready for licensure. Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 06/28/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2022

LIC809 (FAS) - (06/04)

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