197610354-1-9-2024-31-AS-CALH-CZBUJK-20240109143740

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610354
Report Date: 01/09/2024
Date Signed: 01/09/2024 02:39:09 PM

Document Has Been Signed on 01/09/2024 02:39 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:	PENDLETON HOUSE		FACILITY NUMBER:	197610354
ADMINISTRATOR:	KARIBIAN, MARY MARO		FACILITY TYPE:	740
ADDRESS:	12016 PENDLETON STREET		TELEPHONE:	(818) 822-0911
CITY:	SUN VALLEY	STATE: CA	ZIP CODE:	91352
CAPACITY:	6	CENSUS: 5	DATE:	01/09/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Mary Maro Kariban		TIME COMPLETED:	02:36 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	On 01/09/2024 at 09:00 AM, Licensing Program Analyst (LPA) Christopher Alemoh conducted an unannounced Required – Annual Continuation Inspection and met with Administrator Mary Maro Kariban four (4) residents and two (2) staff were present during this inspection. Facility Is following COVID mitigation protocols. At 09:30 AM LPA Alemoh conducted a physical plant to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Facility temp noted at 75 degrees. Facility is licensed to serve elderly residents aged 60 and above. Facility is cleared for non-ambulatory and bedridden residents. Facility also has an approved hospice waiver for 6 (6) residents. The Annual Licensing Fees are current. The facility is a single-story structure with four (4) Resident rooms: Rm 3 and Rm 4 serve two (2) bedridden residents, Rm 1 and Rm 2 serve one (1) bedridden resident, staff room, living room, dining room, and kitchen. LPA accessed facility through rear alleyway. S1 accompanied LPA inside and outside the facility during this inspection. Outside grounds were toured and no bodies of water were observed. Walkways around the home were clear of hazards. There were four (4) bedrooms designated for residents' all rooms were properly furnished with appropriate beddings and linens with sufficient lighting. Resident bedrooms had the required furniture, bed linens and closet/drawer space to accommodate each resident comfortably. There are no security bars or weapons on the premises.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

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: PENDLETON HOUSE	FACILITY NUMBER: 197610354
	VISIT DATE: 01/09/2024

NARRATIVE

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(Cont From 809)

There are two (2) bathrooms designated for residents' use. Toilets and water faucets worked properly, grab bars were secure, shower was free of mold/mildew and a non-skid mat was in place, hot water temperature properly measured between 110F-111F. Resident bath towels, toiletries and personal hygiene supplies were adequately stocked.

Common areas were clean and clear of hazards, doorways were free of obstructions.

Laundry area is located in the garage LPA observed area to be clean and appliances in good repair. PPE’s and emergency supplies are stored in two (2) industrial sized cabinets, both are locked and secured.

LPA toured the kitchen area and observed a two day supply of perishable and a seven day supply of non-perishable food in cabinets above the countertop. Knives were stored in locked cabinet and toxics were observed under the sink inaccessible to residents. Appliances observed to be in good repair and functioning. First Aid kit and manual was attached wall near the backyard entrance. There is One (1) fire extinguishers in the facility. Extinguisher was observed to be charged with receipt dated May 23rd, 2023. Dual Smoke alarms and carbon monoxide are hardwired and interconnected, were tested and observed to be operable. Fire/earthquake drills are completed quarterly.

At 10:13 AM LPA conducted a file review.
LPA reviewed three (3) staff records, 3 out of 3 staff records had current first aid certificates and had required criminal record clearances or criminal record exemptions.

LPA reviewed five (5) resident records were reviewed and, 5 out of 5 client records had Admission Agreements, Medical Assessments, Pre-appraisals (or Reappraisals) and/or Needs & Services Plans.
Medication and Medication Records were reviewed for proper documentation.

No deficiencies cited.

An exit interview was conducted. A copy of this report and appeal rights were left with Administrator Mary Maro Kariban.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Christopher Alemoh	TELEPHONE: 818-669-6375
LICENSING EVALUATOR SIGNATURE:	DATE: 01/09/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/09/2024

LIC809 (FAS) - (06/04)

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