197610417-9-12-2023-31-AS-ADUA-CVLUUB-20230912155317

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610417
Report Date: 09/12/2023
Date Signed: 09/12/2023 03:54:03 PM

Document Has Been Signed on 09/12/2023 03:54 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:	ADVERTENCE SENIOR CARE		FACILITY NUMBER:	197610417
ADMINISTRATOR:	PO, GELENE		FACILITY TYPE:	740
ADDRESS:	6930 NESTLE AVE.		TELEPHONE:	(747) 287-8543
CITY:	RESEDA	STATE: CA	ZIP CODE:	91335
CAPACITY:	6	CENSUS: 4	DATE:	09/12/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Gelene Po, Licensee		TIME COMPLETED:	04:00 PM

NARRATIVE

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Licensing Program Analysts (LPAs) Abeye Duguma, Leslie Ngo-Castaneda and Huma Rahimi conducted an announced Pre-licensing visit at 09:30 AM and met with the Licensee, Gelene Po. LPAs conducted an entrance interview with the Licensee. This is a change of ownership visit from INFINITY SENIOR CARE LLC (197610279) to ADVERTENCE SENIOR CARE (197610417). LPAs also observed that there were four (04) residents during the inspection. All residents appear to be clean and groomed.

With the assistance of the Licensee, LPA conducted a facility tour of both the inside and outside. This is a single-story property. Fire Clearance is approved for six (06) non-ambulatory of which one (01) may be bedridden. Facility has five (05) bedrooms and three (03) full bathrooms. One (01) out of five (05) bedrooms is semi-private and the remaining are all private single occupancy. All residents’ bedrooms were adequately furnished. The facility has a designated staff restroom. Resident bathrooms have properly installed grab bars and shower has non-skid mats. The average hot water temperature measured at 118.5ºF during the visit.

The common areas were appropriately furnished. The LPA observed entertainment equipment and games for activities. The facility has a designated storage cabinet for residents and staff records located in the hallway area. The first-aid kit is complete. The facility has adequate linen, water, and emergency kits. The linens were stored in the storage space located in the hallway.

LPA observed a fireplace that was blocked with a screen. Smoke and Carbon Monoxide detectors were checked and function properly. There is a fully charged fire extinguisher located in the kitchen area. Receipt shows that fire extinguisher was purchased on 07/22/2023 and LPA advised the Licensee to retain the receipt of the fire extinguisher identifying the purchase date to ensure the time frame for annual inspection.

(CONT on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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: ADVERTENCE SENIOR CARE	FACILITY NUMBER: 197610417
	VISIT DATE: 09/12/2023

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LPAs observed a washer and dryer in the laundry room near rear entrance. All chemicals, additional personal hygiene items were stored in the laundry room. The medications are stored in a locked cabinet located in the hallway.

LPA inspected the kitchen and observed stove and refrigerator to be clean and working. Knives and sharps are stored in a locked kitchen drawer.

There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

At the time of this visit the physical plant is meeting Title 22 requirements.

Component III was completed with the LPAs.

No health and safety hazard were noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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