197610343-11-27-2023-31-AS-HRAI-CXYVJA-20231127152825

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610343
Report Date: 11/27/2023
Date Signed: 11/27/2023 03:31:30 PM

Document Has Been Signed on 11/27/2023 03:31 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:	ST. MARTIN RESIDENTIAL CARE LLC		FACILITY NUMBER:	197610343
ADMINISTRATOR:	FERIDO, JAY KERR		FACILITY TYPE:	740
ADDRESS:	18807 COVELLO STREET		TELEPHONE:	(562) 881-2446
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 2	DATE:	11/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:52 AM
MET WITH:	Jaykerr Ferido		TIME COMPLETED:	03:20 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	At 9:52 am, on 11/27/2023, Licensing Program Analyst (LPA) Huma Rahimi, conducted an unannounced annual inspection. LPA met with caregiver Kim Trazo and disclosed the reason for the visit. At 10:30 am Administrator arrived. LPA and Administrator toured the facility inside and out. No immediate health and safety risks were observed. The facility is a single story building with six (6) bedrooms, three (3) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (6) non-ambulatory residents, of which one (1) may be bedridden in Bedroom three (3). The facility serves residents with dementia. Approved hospice waivers for six (6). Upon entry, LPA observed a maintained front yard. Signs were posted which directed visitors to the rear of the facility towards the main entrance. There, signs were posted for the facility’s masking requirement, as well as a sign which read “No smoking – Oxygen in Use”. Additional postings inside included confidential complaint contacts, Ombudsman contacts, emergency disaster plan, resident rights, rights of resident councils, theft and loss policy, non-discrimination notice, COVID precautions, and administrator certificate. Kitchen: At approximately, 10:35 am LPA toured the kitchen area and observed enough supplies, appliances were in working condition and clean. Enough supplies of staple non-perishable and perishable. All knives and sharps observed to be locked in a kitchen cabinet and inaccessible to clients in care and cleaning solutions were locked under the sink. LPA measured the refrigerator and freezer temperatures to be 37 and 0 degrees Fahrenheit, respectively. The stove hood was clean, and all surfaces were sanitary. A facility menu was posted. Appliances were functional. Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

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 3

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: ST. MARTIN RESIDENTIAL CARE LLC	FACILITY NUMBER: 197610343
	VISIT DATE: 11/27/2023

NARRATIVE

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Medications: At approximately, 10:40 am LPA observed medications are centrally stored and locked next to the kitchen in a separate cabinet.

Bedrooms: at approximately 10:45 am LPA toured the bedrooms and observed that there are six (6) bedrooms. All bedrooms were private except bedroom number four (4). Bedroom # six (6) was designated for staff. The Administrator noted that the staff room is always locked. Bedroom # three (3) and Bedroom # five (5) contained residents. Bedroom # three (3) resident is using oxygen, and Bedroom # five (5) resident doesn’t use oxygen currently. Both bedrooms had appropriate signs. All verbal residents reported being in good condition. A ramp and sturdy hand rail led out from Bedroom #3. All bedrooms contained a chair, nightstand, lamp, flashlight, storage, and bed with adequate bedding. All furnishings were clean and in good repair. Residents were provided bells to call staff.

Bathroom: At approximately 11:00 am LPA observed three (3) bathrooms in the facility. Two (2) bathrooms are private, and one (1) is shared. All bathrooms contained liquid soap, paper towels, hand washing 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 11:05 am, LPA measured the water temperature in the shared bathroom to be 117.5 degrees Fahrenheit.

Common Areas: The facility maintains a comfortable temperature at 73°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture and the fireplace is adequately screened. No obstructions and or tripping hazards throughout the facility. The fire extinguisher was purchased on 07/11/2023.

Laundry Room: An operable washer and dryer were located in the locked garage. Detergent was stored in a separate, locked cabinet. Paper supplies, emergency water, and other essential needs devices were also stored in the garage.

Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: ST. MARTIN RESIDENTIAL CARE LLC	FACILITY NUMBER: 197610343
	VISIT DATE: 11/27/2023

NARRATIVE

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Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 11:20am they were tested and observed to be operational. Carbon monoxide was located in a hallway by bedroom # one (1) and was also tested and observed to be operational.

Outside areas: At approximately, 11:30 am LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients.

Between 11:45 pm to 3:00 pm, LPA reviewed records of two (2) clients and four (4) staff. Client and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC.500.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Huma Rahimi	TELEPHONE: (818) 304-2399
LICENSING EVALUATOR SIGNATURE:	DATE: 11/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/27/2023

LIC809 (FAS) - (06/04)

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