197610317-3-12-2024-31-AS-GSAO-D3AUTK-20240312155203

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610317
Report Date: 03/12/2024
Date Signed: 03/12/2024 03:52:21 PM

Document Has Been Signed on 03/12/2024 03:52 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:	CASA MARINA RESIDENTIAL CARE		FACILITY NUMBER:	197610317
ADMINISTRATOR:	ADAMS, EULRONDA		FACILITY TYPE:	740
ADDRESS:	17029 ROMAR STREET		TELEPHONE:	(805) 368-4972
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 5	DATE:	03/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:03 PM
MET WITH:	Eulronda Adams		TIME COMPLETED:	04:05 PM

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On 03/11/24 at 12:03PM, Licensing Program Analyst (LPA) Gina Saucedo, arrived to conduct an unannounced, annual inspection at the facility. Upon arrival, LPA Saucedo met with caregiver Esther Inez and disclosed the purpose of the visit. Eulronda Adams, the administrator arrived about thirty (30) minutes later.

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

A physical tour was conducted at 12:55 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 rsidents. The kitchen area was clean at the time of the tour. There is a telephone line on the counter in the kitchen on your right-hand side. There is extra, food in the kitchen pantries. The sharps/knives are at the top of the kitchen counter on your left-side locked and inaccessible to the residents.

The medications are locked and inaccessible to the residents in the pantry area of the hallway. The first aid kit is with the medication in the pantry.

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. The outside/backyard can be accessed from the kitchen area living and dining room area.

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: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

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: CASA MARINA RESIDENTIAL CARE	FACILITY NUMBER: 197610317
	VISIT DATE: 03/12/2024

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There is a garage that can be accessed from the kitchen area. The garage has an extra refrigerator and pantries with dry food, canned goods, gallons of water for emergency use. The washer and dryer is located in the garage with the chemicals locked and inaccessible in a pantry area.

The fire extinguisher is located against the wall on your left-hand side of the entrance of the facility in the kitchen. It is fully charged. The expiration date is 03/2025.

Bedrooms: There are five (5) bedrooms and three (3) full bathrooms. There are two (2) bedrooms that are single, occupied and two (2) shared rooms for residents. There is a staff bedroom with a private bathroom for staff use only. All bedrooms and bathrooms were toured and were properly furnished and have appropriate bedding, linens, toiletry, and lightning. The bathrooms have proper toiletry, grab bars and non-skid mats. The bathroom temperatures of the water are within regulations reading at 114–116-degree Fahrenheit.

The dining/living room area has enough seating for the residents and the staff. There is a fireplace that is covered and inaccessible to the residents. The dining room area has a television and internet access.

The house temperature is at 71-degree Fahrenheit.

There are several smoke detectors/carbon monoxides in the dining/living area that are operable.

Administrative: There is no annual fee that is due right now. At the entrance of the facility against the right-side of the facility there is a billboard with signs: Yes, Disaster Plan, Personal Rights, Food Menu, Rights of Resident Council and Theft and Loss Policy.

An exit interview was conducted, no citation(s) were issued, and a copy of this report was given to the administrator.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 03/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/12/2024

LIC809 (FAS) - (06/04)

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