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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610309
Report Date: 11/15/2022
Date Signed: 11/15/2022 12:26:16 PM

Document Has Been Signed on 11/15/2022 12:26 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:VALLEY STAR OLIVE VIEW UCLA CRTFACILITY NUMBER:
197610309
ADMINISTRATOR:MARSH, KASEYFACILITY TYPE:
772
ADDRESS:14119 BUCHER AVETELEPHONE:
(818) 290-5307
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 16CENSUS: 0DATE:
11/15/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Kasey MarshTIME COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a pre-licensing visit at 14119 Bucher Ave, Sylmar, CA 91342. LPA met with Administrator Kasey Marsh, Assistant Program Manager Joel Nagler and Program Director Tanya Belvin. The facility is one of (5) Crisis Residential Treatment Programs (CRTPs) at the Restorative Care Village located at the Olive View UCLA Medical Center in Sylmar. The CRTP provides adults, between the ages of (18) through (59) behavioral health crisis with 24/7 intensive treatment in a safe, and homelike setting. The facility is designed for adults dealing with mental health challenges to provide an alternative to hospital, emergency rooms, urgent care or hospitalization. Fire inspection was conducted and cleared on 10/03/2022; with a capacity of (16) adults. There are (2) non-ambulatory rooms, located on the first floor: room #'s 113 and 115.

The physical plant tour included: A two story facility, with the first floor consisting of (4) rooms; (2) shared and (2) private and (3) bathrooms. LPA observed hand-washing signs. The front lobby has a sitting area for visitors, a sign in sheet, and a table for temperature checks and clean station with hand-sanitizer. COVID signs are posted outside on the front door. Postings included visiting policy, complaint procedures, activity schedule, personal rights, facility menu, and Mental Health Patient Rights. Walls, floors, ceilings, windows, were clean and in good repair. Hot water measured 110 and 108 degrees Fahrenheit. First floor has intake office for screening of new admits, that include a shower and a Zapp machine for sanitation of clothes. Janitor closets with cleaning supplies on the first and second floor were locked. Extra linens and hygiene supplies were located in storage closets. The facility has emergency water supplies located behind the facility in a locked storage room. LPA observed sufficient supply of food. Kitchen area, had a refrigerator, freezer, dish washer, and conventional oven. Sharps, knives, and utensils were locked and stored in the dining room area.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/15/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: VALLEY STAR OLIVE VIEW UCLA CRT
FACILITY NUMBER: 197610309
VISIT DATE: 11/15/2022
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The facility's 2nd floor, consisted of (5) shared rooms, with (3) bathrooms. A laundry room and group activity also located on the 2nd floor. All bedrooms contained a chair, night stand, emergency lighting and furnishings were clean and in good condition. Shared rooms contained beds which were at least 6 feet apart for social distance. Bathrooms contained a pull cord for the call system. Laundry machines are located on the first and second floor. Personal hygiene and other facility supplies were observed and locked in storage rooms. Staff office, and medication room located on the 2nd floor. Client and staff files are stored in the staff office. First aid kit observed with Licensing requirements. Fire extinguishers were charged and current. All emergency exits, and passageways were free from obstruction. Smoke detectors are hardwired and connected to local fire department. The outdoor area had furnishings for clients to sit. Facility telephone and facility vehicle was checked and operational.

COVID protocols reviewed: All visitors will be screened and must have a mask. There are no mandates for client mask wearing; but staff must wear mask at all time. New admit, vaccination is optional; but staff hires must be fully vaccinated.

LPA and Administrator reviewed Component III.

Exit interview conducted. Copy of report issued.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 11/15/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2022
LIC809 (FAS) - (06/04)
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