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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601418
Report Date: 12/29/2023
Date Signed: 12/29/2023 12:24:42 PM

Document Has Been Signed on 12/29/2023 12:24 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:BUENA VISTAFACILITY NUMBER:
198601418
ADMINISTRATOR:CAROLYN WESTFACILITY TYPE:
735
ADDRESS:360 ALTA PINE DRIVETELEPHONE:
(626) 791-2516
CITY:ALTADENASTATE: CAZIP CODE:
91001
CAPACITY: 6CENSUS: 4DATE:
12/29/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Nancy Parker, Administrator designeeTIME COMPLETED:
12:30 PM
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At 9:45 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the Staff Rosa Vega. Administrator designee arrived 11:40 am. LPA explained the reason for the visit. Physical tour was conducted with the Staff prior to the Administrator designee arrival and LPA observed the following:

Kitchen: At approximately, 10:00 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen cabinet under the sink.

Medications: At approximately, 10:10 AM LPA observed medications are centrally stored and locked in the dinning room cabinet.

Bedrooms: The facility is fire cleared for six (6) ambulatory residents. LPA observed total of three (3) bedrooms designated for clients use. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has an awake staff.

Bathrooms: LPA observed two (2) bathrooms and both appeared to be clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed appropriate grab bar and client's bathroom had non-skid mat. LPA observed appropriate hand washing signs posted in each bathroom. At 10:20 AM hot water temperature measured at 113.2°F.



Common Areas: The facility maintains a comfortable temperature at 70°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility.
Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/29/2023
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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: BUENA VISTA
FACILITY NUMBER: 198601418
VISIT DATE: 12/29/2023
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The Laundry Room: The garage is currently being used for storage and laundry. Laundry detergents, cleaning agents and other toxins are locked away.

Outside areas: At approximately, 10:35 AM LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for clients. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients.

Smoke detectors/carbon monoxide. Smoke detectors were located throughout the facility, and at 10:45 AM they were tested and observed to be operational. Carbon monoxide was located in a hallway and was also tested and observed to be operational.



Between 10:50 AM to 12:15 AM, LPA reviewed records of four (4) clients and two (2) staff. Client and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500 and Administrator certificate.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.


SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/29/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/29/2023
LIC809 (FAS) - (06/04)
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