197610355-2-7-2023-31-AS-APAA-CNTQW9-20230207113135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610355
Report Date: 02/07/2023
Date Signed: 02/07/2023 11:32:15 AM

Document Has Been Signed on 02/07/2023 11:32 AM - 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:	B AND B SENIOR II		FACILITY NUMBER:	197610355
ADMINISTRATOR:	BAINGAN, GLADELYN P.		FACILITY TYPE:	740
ADDRESS:	22755 FESTIVIDAD DRIVE		TELEPHONE:	(661) 600-2838
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91354
CAPACITY:	6	CENSUS: 0	DATE:	02/07/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Gladelyn Baingan, Admnistrator		TIME COMPLETED:	12:00 PM

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At 10:00am, Licensing Program Analyst (LPA) Angela Panushkina conducted an announced Pre-Licensing visit to this facility and met with the Administrator. This is an initial application. The purpose of today’s visit is to inspect the facility to ensure that it maintains compliance under California Code of Regulations, Title 22, Division 6.

Today’s site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The facility has dual carbon monoxide and smoke alarm system. There are two (2) fire extinguishers, with a date of purchase of 12/17/2022. There will be a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are five (5) bedrooms designated for resident use. Resident bedrooms were observed to be appropriately furnished. The facility will have an awake staff.

The common areas (living room, kitchen, and dining areas) were appropriately furnished, and lighting was adequate. The living room has a television and comfortable furniture. Resident, staff records and medication will be stored in a locked closet near the kitchen. The first aid kit is readily available. There are two (2) bathrooms in the facility. Bathrooms have non-skid mats and appropriate grab bars. Trash cans were observed to have closed tight fitting lids.

The kitchen knives are stored in a locked drawer. The kitchen cleaning supplies are stored in a locked cabinet near the stove. Laundry detergents, cleaning supplies and other toxins are stored in the designated laundry room, which leads to the garage. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

Continue on LIC9099-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

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: B AND B SENIOR II	FACILITY NUMBER: 197610355
	VISIT DATE: 02/07/2023

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There will be a sitting area in the backyard for residents to conduct outdoor activities. There is a swimming pool, that was observed to have a five foot fence surrounding its parameters, and a locked gate at entry. The outdoor, front and back yards were free of any obstruction.

Component III was conducted with applicant.

No deficiencies issued with this report. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. Exit interview was conducted. A copy of this report was signed and delivered.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 02/07/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/07/2023

LIC809 (FAS) - (06/04)

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