197610478-1-31-2024-31-AS-GSAO-CZZST2-20240131130850

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610478
Report Date: 01/31/2024
Date Signed: 01/31/2024 01:09:40 PM

Document Has Been Signed on 01/31/2024 01:09 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:	RINALDI CARE HOME		FACILITY NUMBER:	197610478
ADMINISTRATOR:	HARUTYUNYAN, VAHAGN		FACILITY TYPE:	740
ADDRESS:	16750 RINALDI ST		TELEPHONE:	(818) 322-8838
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 0	DATE:	01/31/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	VAHAGN HARUTYUNYAN		TIME COMPLETED:	01:20 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	On 01/31/24, at 09:25am, Licensing Program Analyst (LPA), Gina Saucedo, conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to CCLD on 08/09/2023, Initial license for a Residential Care Facility for the Elderly, 60 years and older. The requested capacity is for one (1) ambulatory, four (4) non-ambulatory of which may be ambulatory, and one (1) bedridden, total of up to six (6) residents. Facility is a single-story home. Today's site visit consisted of LPA touring the physical plant at 10:15 AM inside and outside and observed the following: Bedrooms Staff: There is no bedroom designated for awake staff. Bedrooms Residents: There is a total of four (4) bedrooms. BEDROOMS APPROVED FOR ONLY AMBULATORY SHALL NOT BE USED FOR NON-AMB, PER 85087. There shall be no more than two clients per bedroom. Bedrooms #1 (one) is for ambulatory occupancy, bedroom number two (2) is for bedridden occupancy, and is cleared by the Fire Safety Inspection Request. Bedroom number three (3) will be a shared bedroom and bedroom number four (4) has a private bathroom. All the bedrooms have proper bedding, chairs, night stands, lamps in addition to overhead lighting. 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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: RINALDI CARE HOME	FACILITY NUMBER: 197610478
	VISIT DATE: 01/31/2024

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin, bath-tub/shower. The bathrooms have appropriate grab bars and non-skid mats. There is one bathroom that will accommodate non-ambulatory clients in a wheel chair There is a private bathroom in room number four (4).

The dining/living room has enough seating for staff and residents. The furniture is in good condition.

Linens & Hygiene Supplies:
Adequate supply of linen stored in the cabinets next to the bedrooms.

Emergency Phone Numbers, Exit Plan & Menu:

The facility has a working phone number land line. Fire Extinguisher located near kitchen door mounted on wall. It is fully charged and has a date of January 05, 2024.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cupboards, inspected and in good repair. Sharps are stored on your right side of the kitchen locked and secured. There are toxins under the sink also locked and secured. Food supply adequate stored in several cabinets and consists of the following cereal, canned goods, bottles of water. Dishwasher in kitchen properly installed and functioning. The refrigerator is in good condition and working.

Smoke Detectors:
There are smoke detectors/carbon monoxide through-out the house that were tested and work properly. They are hardwired and interconnected. There is a single carbon monoxide in the kitchen plugged in next to the sink.

Water Temperature:
The water temperature was tested for the bathrooms are they are within regulation-116.1-117.9 Fahrenheit.

809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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: RINALDI CARE HOME	FACILITY NUMBER: 197610478
	VISIT DATE: 01/31/2024

NARRATIVE

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Medications, First-Aid Kit & Book Resident & Staff Files:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in the kitchen area. The resident/staff files will be kept in an office area next to the living room/dining room area. The medication will also be kept in this area secure, locked and inaccessible to the residents.

Pool/Jacuzzi:
There is no pool/jacuzzi in the facility.

Fire clearance:
Fire Clearance was approved on 01/17/2024 signed and dated.

Signal system:

The facility does have a signal system installed.

Administration:
The facility had submitted a Mitigation and Infection plan. The insurance plan, House Rules, Resident Rights, Rights of Resident by Council, Theft and Loss Policy and YES sign are at the entrance of the facility against the wall on your right side. Component III was shown to the Administrator, orientation process was completed.

Structure:
Overall Facility is a four (4) bedroom, two (2) bathroom, single-story house with a car attached garage in the back of the facility. The home has a gas fire place in the living room with a metal screen cover, and is inaccessible to the residents. There is a back yard where there is one (1) washer and dryer are located on your left-hand side of the facility along with toxins which is in a locked area and inaccessible to the residents.

Pre-licensing:
Facility is in compliance with Title 22 Regulations at this time. 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 conducted and copy of this report issued.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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