197610547-4-29-2024-31-AS-GSAO-D4SQLN-20240429121615

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610547
Report Date: 04/29/2024
Date Signed: 04/29/2024 12:17:02 PM

Document Has Been Signed on 04/29/2024 12:17 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:	7 TWO 5 INC		FACILITY NUMBER:	197610547
ADMINISTRATOR:	SAAKIAN, ANNA		FACILITY TYPE:	740
ADDRESS:	9524 ENCINO AVE		TELEPHONE:	(323) 408-9600
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91325
CAPACITY:	6	CENSUS: 0	DATE:	04/29/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Anna		TIME COMPLETED:	12:30 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 04/29/24, at 9:35am, 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 Community Care Licensing Division-CCLD on 10/2023, Initial license for a Residential Care Facility for the Elderly, 60 years and older. The requested capacity is for five (5) non-ambulatory and one (1) bedridden, total of up to six (6) residents. There is a side room outside which is considered a family room and it has a full bathroom. Facility is a single-story home. Today's site visit consisted of LPA touring the physical plant at 9:50 AM inside and outside and observed the following: Bedrooms Staff: The side, family room is designated for staff ONLY no residents are to be in this area and/or room. Bedrooms Residents: There is a total of five (5) bedrooms. There shall be no more than two clients per bedroom if used for non-ambulatory. Only one (1) bedroom is cleared for bedridden which is bedroom # 5 (five). Bedroom #5 (five) has a private full bathroom. There is another full bathroom in between rooms two (2) and three (3). There is another half bathroom by the washer and dryer area. The bathrooms have proper grab bars and non-skid mats. All the bedrooms have proper bedding, chairs, nightstands, lamps in addition to overhead lighting. LIC 809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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: 7 TWO 5 INC	FACILITY NUMBER: 197610547
	VISIT DATE: 04/29/2024

NARRATIVE

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

Garage:
There is a garage that has another refrigerator. There is access to the garage from the washer and dryer area which is locked and inaccessible to the residents. The washer and dryer area has a half bathroom. The washer and dryer area can be accessed from the kitchen area with a key.

Linens & Hygiene Supplies:
Adequate supply of linen (bedding/linen) stored in three (3) cabinets by the hallway near bedrooms two (2) and four (4).

Emergency Phone Numbers, Exit Plan:

The facility has a working phone number land line on the kitchen counter. Fire Extinguisher located in the kitchen on your left-hand side mounted on the wall. It is fully charged and has a date of 10/23.

Kitchen/Food Service:
Dishes, cups, and flat ware are stored in the kitchen cupboards, inspected and in good repair. Sharps are stored on your left-side of the kitchen locked and secured inaccessible to the residents. The chemicals will be stored under the sink locked and inaccessible to the residents. Food supply adequate stored in several cabinets and consists of the following: canned goods, bottles of water, cereal, emergency buckets. The refrigerator and stove are in good condition and working. The medication cabinet is locked and inaccessible to the residents on your left-side of the kitchen. The first aid kit is next to the medication cabinet.

809C-continued

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

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: 7 TWO 5 INC	FACILITY NUMBER: 197610547
	VISIT DATE: 04/29/2024

NARRATIVE

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Smoke Detectors:
There are smoke detectors/carbon monoxide through-out the house that were tested and work properly. They are hardwired and interconnected with the doors for an emergency.

Water Temperature:
The water temperature was tested for the bathrooms are they are within regulation:116.-118 Fahrenheit.

Pool/Jacuzzi:
There is a pool in the backyard which is wired, fenced and locked inaccessible to the residents.

Fire clearance:
Fire Clearance was approved on 03/08/2024 signed and dated.

Signal system:

The facility does have a signal system installed.

Administration:
The facility had submitted a Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Infection plan. These signs are located at the entrance of the facility: Personal Rights of Residents, Rights of Resident Council, Family Council, Infection Control, Emergency and Disaster Plan, Theft and Loss Policy, YES, the facility sketch is located throughout the house.

The Component III Orientation was shown to the Administrator.

Structure:
Overall Facility is a five (5) bedroom home with two (2) and a half bathroom, single-story home with an outside ramp. There is a family room attached to the house which has the fire clearance and will only be used for staff. There is a garage attached to the house. The home does not have a fireplace which is covered in the dining area. There is one (1) washer and dryer located next to the kitchen which is locked and inaccessible to the residents. The house also has a pool.

SUPERVISOR'S NAME: Troy Agard	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR NAME: Gina Saucedo	TELEPHONE: (818) 304-3057
LICENSING EVALUATOR SIGNATURE:	DATE: 04/29/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/29/2024

LIC809 (FAS) - (06/04)

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