197610590-9-11-2024-31-AS-MCAA-D8ZPX4-20240911114142

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610590
Report Date: 09/11/2024
Date Signed: 09/11/2024 11:41:52 AM

Document Has Been Signed on 09/11/2024 11:41 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ANDREW'S BOARDING CARE		FACILITY NUMBER:	197610590
ADMINISTRATOR:	ANDRADE, ARCELI		FACILITY TYPE:	740
ADDRESS:	17441 HIAWATHA AVENUE		TELEPHONE:	(323) 304-4567
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 3	DATE:	09/11/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Araceli Andrade, Violeta Tagactac		TIME COMPLETED:	11:45 AM

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	Licensing Program Analyst (LPA) Michael Cava conducted a Pre-Licensing Inspection with the applicant representative/administrator, Araceli Andrade and staff, Violeta Tagactac. A Change in Ownership (CHOW) Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on February 23, 2024. A fire clearance was approved on August 14, 2024 for five (5) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The applicant is also requesting a hospice waiver to retain two (2) residents. The smoke alarms and carbon monoxide detector are dual and inter-connected. There are two additional carbon monoxide detectors installed in the living room and in the hallway. The facility has one fire extinguisher stationed in the kitchen. The charge date is 05/10/24. A tour of the physical plant was initiated at approximately 10am, after the Component III power point presentation was held. The following was observed: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, toaster oven, stove/oven and sink. There were adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). Knives are kept locked in a kitchen drawer. BEDROOMS: There are a total of seven (7) bedrooms in the facility. Six (6) bedrooms are designated for resident use. One (1) bedroom designated for staff. All six bedrooms are private. The bedridden fire clearance is approved for one (1) resident at any time for either room #5 or #6 (per STD 850). The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ANDREW'S BOARDING CARE	FACILITY NUMBER: 197610590
	VISIT DATE: 09/11/2024

NARRATIVE

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BATHROOMS: The facility has five (5) bathrooms. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured between 105-107 degrees.

COMMON AREAS: These included the living room and dining room areas. The living room is furnished with a couch, recliners and television. The dining room is furnished with a dining room table to seat six (6). The fireplace in the dining room is properly screened. No key or fireplace tools present. Floors were mopped and clean. Hallways and passageways clear of obstruction.

LAUNDRY ROOM: The laundry room is located adjacent to the kitchen. Cleaning supplies are kept in a locked cabinet. Emergency food supply are kept in another cabinet, separate from the cleaning supplies.

MEDICATIONS: Medications and medication records are kept locked in a closet by the entrance. 1st aid kit and manual also maintained with medications in the same closet.

STAFF/RESIDENT RECORDS: Staff and resident records are also maintained in the medication closet by the front entrance.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio area and sufficient yard space. No swimming pool or any bodies of water on the property. There is no garage, but there are two locked storage spaces located at the front. Old/previous facility records are kept locked in one storage space. Excess wheelchair, bed/furniture, kept locked in the other storage space.

COMPONENT III: In addition to the Pre-Licensing inspection, a Component III power point presentation was held prior to the walk through.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 09/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2024

LIC809 (FAS) - (06/04)

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