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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610301
Report Date: 11/08/2023
Date Signed: 11/08/2023 03:36:59 PM


Document Has Been Signed on 11/08/2023 03:36 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:COLUMBIA CARE HOME INCFACILITY NUMBER:
197610301
ADMINISTRATOR:SANTOS, RIE ULYSSESFACILITY TYPE:
740
ADDRESS:23946 COLUMBIA CTTELEPHONE:
(818) 428-5352
CITY:VALENCIASTATE: CAZIP CODE:
91355
CAPACITY:6CENSUS: 4DATE:
11/08/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:39 AM
MET WITH:Jocelyn SinonTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Jocelyn Sinon for a One (1) Year Required annual inspection visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 09:40am and the following was noted:
The facility has a total of five (5) bedrooms, five (5) of which are designated for resident use. Resident bedrooms were observed to be appropriately furnished. There are three (3) bathrooms in the facility and were observed to have non-skid mats and appropriate grab bars installed. The facility is fire cleared for five (5) non-ambulatory and one (1) bedridden resident. The facility is currently occupying four (4) residents present in the facility of which three (03) are receiving hospice services. All residents appear to be clean and groomed.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is currently being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are locked away.



Kitchen is sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

Living and dining room furniture were also checked. The living and dining room are neat and clean. The facility maintains a comfortable temperature at 75°F.

(continued on LIC 809-C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:
DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/08/2023
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: COLUMBIA CARE HOME INC
FACILITY NUMBER: 197610301
VISIT DATE: 11/08/2023
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The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is in the kitchen, observed to be full and last purchased on 09/22/2023.

The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 114.8°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinets. LPA observed medication and first aid kit to be locked and inaccessible to residents.

No health and safety hazards noted.

Exit interview was conducted and with a copy of this report was issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye DugumaTELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:

DATE: 11/08/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023
LIC809 (FAS) - (06/04)
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