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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610627
Report Date: 09/10/2024
Date Signed: 09/10/2024 12:56:12 PM

Document Has Been Signed on 09/10/2024 12:56 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VIDA HOME SERVICES AT TUJUNGAFACILITY NUMBER:
197610627
ADMINISTRATOR/
DIRECTOR:		BALQUIEDRA, CHERYLFACILITY TYPE:
735
ADDRESS:10227 TUJUNGA CANYON BLVD.TELEPHONE:
(818) 625-7103
CITY:TUJUNGASTATE: CAZIP CODE:
91042
CAPACITY: 4CENSUS: 0DATE:
09/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:17 AM
MET WITH:Cheryl Balquiedra - AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:00 PM
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Licensing Program Analysts (LPAs) Gary Tan and Angelica Segovia conducted an announced Pre licensing visit at this facility on this date. LPAs met with Licensee representative Cheryl Balquiedra and informed the purpose of the visit. A Fire Clearance dated 08/23/24 is approved for four (4) non-ambulatory clients. This will be a North Los Angeles Regional Center (NLARC) vendored facility Level III.

LPAs toured the facility inside and out at 10:30 AM. Dual smoke and carbon monoxide alarms are hard wired and interconnected, tested and observed to be operational. The facility has four (4) client bedrooms and four (4) bathrooms. Each room is furnished with beds, lights, night stands and chair. One additional (1) bedroom and bathroom is designated for staff use. Sufficient closet space was observed for each room. Medication will be stored in a cabinet in the living room. Medication storage is equipped with a lock to ensure medications will not be accessible to clients. Storage for client and staff records are also observed to be locked in the same cabinet. There is a working telephone and internet services on the premises.

Common areas were appropriately furnished and lighting was adequate. LPAs observed a fully charged fire extinguisher in the dining room which was last inspected on 08/06/24. A complete first aid kit was observed to be kept inside the medication cabinet. The water temperature in client restrooms was measured at a range of 116.7°F to 118.9°F. Appliances in the kitchen were clean and all appeared functional. The laundry room has new washer and dryer which are properly installed. Laundry detergent and other cleaning supplies are stored in a locked cabinet inside the laundry room located along the bedroom hallway. There is no body of water in the facility. (continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/10/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VIDA HOME SERVICES AT TUJUNGA
FACILITY NUMBER: 197610627
VISIT DATE: 09/10/2024
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(continued from LIC 809)

There is no garage at the facility, only a gated car port. The backyard of the facility was also inspected to ensure compliance. The backyard activity area is free of obstruction. Outdoor furniture is also observed in the patio. There is a one bedroom guest house within the compound, it is intended to be a staff quarter once the facility becomes operational. There is also a basement storage where the tools and old equipment are stored. An office adjacent to the basement is currently under construction but will be ready once the facility is operational as they are still waiting to be vendorized by the NLARC. The exterior passageways and exits were clean and clear of any obstructions. No other health and safety hazard present.

Component III is waived as the Administrator has more than six (6) years of experience as co-Administrator in another same level facility with the approval of LPM Troy Agard.

The facility appears to be compliant with regulations. A copy of this report will be submitted to the application specialist for final review.

An exit interview was conducted and a copy of this report Issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024
LIC809 (FAS) - (06/04)
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