198600369-3-9-2023-29-AS-CYEE-CPQVX8-20230308154907

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198600369
Report Date: 03/08/2023
Date Signed: 03/09/2023 10:47:05 AM

Document Has Been Signed on 03/09/2023 10:47 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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ADLA INC. #1		FACILITY NUMBER:	198600369
ADMINISTRATOR:	AIDINOVA, SALBI		FACILITY TYPE:	735
ADDRESS:	14318 RUNNYMEDE STREET		TELEPHONE:	(818) 787-6532
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91405
CAPACITY: 4		CENSUS: 4	DATE:	03/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Liana Aidinova, Licensee		TIME COMPLETED:	04:00 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	Licensing Program Analyst (LPA) Christine Yee conducted an unannounced required Annual Inspection and was let into the home by Raelynn Urbanski, Staff. Liana Aidinova, Licensee, was contacted by telephone and arrived at 09:25am to conduct the visit. The reason for today's visit was explained. The facility is a single storey family home consisting of 4 bedrooms of which 1 is used by live-in staff, a living room, a dining room, a kitchen and 3 full bathrooms. The home is fire cleared for 4 AMBULATORY clients. On today's visit the annual inspection was completed using the Compliance and Regulatory Enforcement(CARE)Tool. The facility met the regulatory requirements of the CARE tool. A tour of the home was also conducted, inside and outside, and below were observed: The 3 client bedrooms had the required Title 22 furniture, closet, lamp and bed linens. The windows all had the appropriate window dressing The living room and dining room had sufficient seating for the capacity Sufficient perishable and non-perishable foods were observed Continued on LIC9099-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 3

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ADLA INC. #1	FACILITY NUMBER: 198600369
	VISIT DATE: 03/08/2023

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
26
27
28
29
30
31
32

The only fire extinguisher located in the Kitchen was full and last tested on 12/2/22.
Carbon Monoxide detector located in the dining room was tested and was operational
The interconnected smoke detectors were tested and were operational
The water was tested in the common bathroom three times and had readings of 123.6, 124.7 and 122.5 degrees Fahrenheit. The last test was conducted at 2:59pm
Medications were locked in a locked cabinet in the laundry room
Knives and toxins were locked in the laundry room
The backyard and front yard were observed to be clean and has no body of water.
The backyard has a covered patio with tables and chairs.

Deficiencies were cited under California Code of Regulations, Title 22, Division 6, Chapter 1.

Exit Interview was conducted, Appeals Rights discussed and a copy of the report was provided.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Christine Yee
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3

Document Has Been Signed on 03/09/2023 10:47 AM - It Cannot Be Edited

Created By: Christine Yee On 03/08/2023 at 03:25 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ADLA INC. #1	FACILITY NUMBER: 198600369
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

80088(e)(1)

Fixtures, Furniture, Equipment, and Supplies

(e) Faucets used by clients for personal care such as shaving and grooming shall deliver hot water. (1) Hot water temperature controls shall be maintained to automatically regulate temperature of hot water delivered to plumbing fixtures used by clients to attain a hot water temperature of not less than 105 degrees F (40.5 degrees C) and not more than 120 degrees F (48.8 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on testing /observation, the licensee did not comply with the section cited above in 1 out of 1 which poses an immediate health, safety or personal rights risk to persons in care. Water was tested 3 times and had the following readings 123.6, 124.7 and 122.5 degrees Fahrenheit
	POC Due Date: 03/09/2023
	Plan of Correction
1 2 3 4	The Licensee will adjust the thermostat to ensure that the water temperature is within Title 22 requirement of 105 to120 degrees Fahrenheit. Provide evidence that the deficiency was corrected by 3/9/23

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Christine Yee

LICENSING EVALUATOR SIGNATURE:

DATE: 03/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2023

LIC809 (FAS) - (06/04)

Page: 3 of 3