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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610468
Report Date: 03/18/2024
Date Signed: 03/18/2024 11:21:09 AM

Document Has Been Signed on 03/18/2024 11:21 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PT PREFERRED LIVING INC.FACILITY NUMBER:
197610468
ADMINISTRATOR:TABACHNIKOV, PAULFACILITY TYPE:
735
ADDRESS:7806 DE SOTO AVE.TELEPHONE:
(310) 221-1383
CITY:CANOGA PARKSTATE: CAZIP CODE:
91304
CAPACITY: 4CENSUS: 0DATE:
03/18/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Paul Tabachnikov, LicenseeTIME COMPLETED:
11:45 AM
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At 9:20 am, Licensing Program Analyst (LPA), Huma Rahimi conducted an announced Pre-Licensing visit to the above facility and met with Administrator Paul Tabachnikov. LPA conducted an entrance interview with the Administrator. At the time of this visit LPA did not observed any clients present in the facility. Fire Clearance dated 11/29/2023 and received for two (2) Non-ambulatory and two (2) ambulatory clients. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The facility is a single-story building. LPA toured the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPAs observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to clients. Administrator/Licensee was informed that the locking mechanism shall be maintained and inaccessible at all times. At 9:33 AM, LPA observed a full Fire Extinguisher and was last purchased on 01/22/2024.

BEDROOMS: There are six (6) bedrooms of which one is designated for staff and one for an office. Four (4) bedrooms are designated for clients use. Bedroom # one (1) and bedroom # two (2) is for non-ambulatory clients. Bedroom # three (3) and bedroom # five (5) is for ambulatory clients. Bedroom # four (4) is for a live-in staff use and LPA did not observe any obstruction or hazard. LPA observed that all client’s bedrooms were furnished with beds, chest drawers, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting.



Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/18/2024
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 2
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: PT PREFERRED LIVING INC.
FACILITY NUMBER: 197610468
VISIT DATE: 03/18/2024
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BATHROOMS: At 9:42 am, LPA observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. All bathrooms observed to have appropriate grab bar and a non-skid mat . At 9:45 am, the water temperature was noted at 118.9°.

COMMON AREAS: LPAs observed all common areas to be clean in good repair. The facility maintains a comfortable temperature at 72°F. The living room and dining rooms were properly furnished. No obstructions and or tripping hazards throughout the facility.

MEDICATION ROOM: The medication and facility staff/clients files will be kept in a locked cabinet located in the in the corner of the dining room.

LAUNDRY ROOM: The laundry room is located in the hallway by bedroom # one (1) and two (2). LPA observed a door with a lock. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

SURROUNDING GROUNDS: The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, LPA observed a covered shaded area for clients. There is no swimming pool or bodies of water at the facility.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility and hardwired. At 9:47 am, they were tested and observed to be operational.


Component III was conducted with the Administrator.

Pursuant to Title 22, the facility is compliant to regulation, and ready for licensure. This report will be forwarded to the Centralized Application Bureau (CAB). The applicant will be notified by the CAB Analyst when their license is approved.



Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 03/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/18/2024
LIC809 (FAS) - (06/04)
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