197610298-3-4-2024-31-AS-GSAO-D32VWF-20240304154752

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610298
Report Date: 03/04/2024
Date Signed: 03/04/2024 03:48:17 PM

Document Has Been Signed on 03/04/2024 03:48 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LINDLEY RESIDENTIAL CARE		FACILITY NUMBER:	197610298
ADMINISTRATOR:	AVETISYAN, ARMENUHI		FACILITY TYPE:	740
ADDRESS:	18124 VINTAGE STREET		TELEPHONE:	(818) 983-2224
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 3	DATE:	03/04/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:01 PM
MET WITH:	Larisa Bobakova		TIME COMPLETED:	04:00 PM

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On 03/04/24 at 1:01 PM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver Larisa Bobakova and disclosed the purpose of the visit.

LPA asked for the census, resident, and staff rosters.

A physical tour was conducted at 1:50 PM and observed the following:

The Kitchen area was toured, and LPA observed there to be sufficient seven (7) day supply of non-perishable foods and perishable food for all residents. The kitchen area was clean at the time of the tour. The fire extinguisher is located against the wall on your right-hand side towards the backyard. It is fully charged. The expiration date is 07/2024. There is a telephone line on the counter in the kitchen. There is extra, food in the kitchen pantries. The medications are locked and inaccessible to the residents in one of the top, black cabinets on your right-hand side at the entrance of the facility. The knives are at the top of the kitchen counter on your right-side in a locked black box and inaccessible to the residents. The first aid kit is on the kitchen counter area on the right-side of the sink.

Outside/Backyard: The outside/backyard has furniture for the residents with proper seating. The facility does have a signal system. The facility does not have a pool/body of water.

LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LINDLEY RESIDENTIAL CARE	FACILITY NUMBER: 197610298
	VISIT DATE: 03/04/2024

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Bedrooms: There are three (3) bedrooms and three(3) bathrooms. There are two (2) bedrooms for residents and one (1) for staff. The staff bedroom has a private bathroom. There are two (2) bedrooms that are shared. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 117-118 degree Fahrenheit.

The dining/living room area has enough seating for the residents and the staff.

There is a pantry/room in the hallway that has extra linen and food storage. It is locked and inaccessible to the residents. The house temperature is at 69-degree Fahrenheit.

The smoke detector/carbon monoxide is in the hallway and is operable.

The washer/dryer along with the chemicals is in the hallway in a locked room, inaccessible to the residents.

Administrative: There is no annual fee that is due right now. Towards the back of the facility on your right-hand side there is a facility sketch, House Rules, Disaster Plan, Resident Rights, Rights of Resident Council, Licensee Expiration dated 01/2025, Wifi connection instructions, Designation of facility, Infection Control and the surety bond with an expiration date of 01/2025.

An exit interview was conducted, no citations were issued, and a copy of this report was issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2024

LIC809 (FAS) - (06/04)

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