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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610526
Report Date: 12/28/2023
Date Signed: 12/28/2023 12:04:55 PM


Document Has Been Signed on 12/28/2023 12:04 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:SENIOR STEWARDS CARE HOMEFACILITY NUMBER:
197610526
ADMINISTRATOR:BELLO, SANDRAFACILITY TYPE:
740
ADDRESS:9130 WOODLEY AVENUETELEPHONE:
(818) 960-4507
CITY:NORTH HILLSSTATE: CAZIP CODE:
91343
CAPACITY:6CENSUS: 2DATE:
12/28/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Sandra BelloTIME COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Tihesha Smith arrived at the facility on 12/28/2023 at 8:00am to conduct an announced Change of Location visit. LPA Smith was greeted by the administrator Sandra Bello and disclosed purpose of the visit. Administrator identity was verified by valid California Driver’s License.

Fire Clearance is approved for 5 non-ambulatory and 1 bedridden resident. LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. First-aid kit is complete; facility has adequate linen, nonperishable food supplies. There is one (1) fire extinguisher in the property located near front door. There is no swimming pool or other body of water. Facility has working alarms on all exits. Front and backyard are fenced.

The kitchen, living and dining room combination area observed to have some furnishings, sufficient lighting and observed to be clean. The kitchen glass table and the living room coffee table to be moved by current tenant by 12/30/2023 per administrator. The laundry room is next to the kitchen: appliances observed to be in good repair. The garage used for storage and is part of the facility however the property owner has items stored in the garage. Administrator revealed owner will have items moved by 12/30/2023.

There are four (4) bedrooms and two (2) bathrooms in the home: with one of the bathrooms in Room #4. The two (2) bathrooms observed to be clean with grab bars, mats, and trash cans with lids. Three (3) of the four (4) rooms were unoccupied and have beds delivered by hospice. Bedroom # 2 has owners personal items stacked by closet door and Room #4 is currently occupied with two (2) tenants. Administrator revealed tenants will be completely out of facility on 12/30/2023. LPA observed tenants in the process of moving items out.

(Cont. to 809C)
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:
DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/28/2023
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: SENIOR STEWARDS CARE HOME
FACILITY NUMBER: 197610526
VISIT DATE: 12/28/2023
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(Cont from 809)

LPA Smith contacted Licensing Program Manager (LPM) Naira Margaryan regarding issues found during the physical plant tour and move out information provided by Administrator. LPM Margaryan spoke with the Administrator and informed her that the facility is not currently ready to be licensed due to the issued discovered. The Administrator also was advised to contact the trustee of the old location and request an extension to last eviction day, by reason of the new location may not be licensed by 12/30/2023. This immediate change of location was a result of the owner defaulting on the old location property located at 9540 Donna Ave Northridge, CA 91324.

LPA Smith conducted an exit interview with the Administrator and informed that the following corrections must be made before completion of pre-licensing visit:

Two (2) tenants currently residing in bedroom #4 must move out immediately. All furniture and personal items must be removed from room and bathroom.

All personal items belonging to owner and/or tenants shall be removed from bedroom #2.

All food, furniture, and personal items belonging to owner and/or tenants need to be removed from the refrigerator, kitchen and living room.

All personal items/equipment belonging to owner shall be removed from garage.

LPA Smith advised the Administrator to contact the LPA when corrections are made and to send pictures to verify that corrections were made.

A conference call between Licensing Representatives, Administrator, and Trustee Lawyer Nancy Zamora was conducted at 11:02 am regarding issues preventing licensing approval today. The trustee provided the administrator with an extension of: 01/10/2024.

Exit interview is completed and a copy of report was issued.

SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha SmithTELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:

DATE: 12/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/28/2023
LIC809 (FAS) - (06/04)
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