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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198601684
Report Date: 08/11/2023
Date Signed: 08/11/2023 12:56:41 PM

Document Has Been Signed on 08/11/2023 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:VALLEY VILLAGE LARKSPUR HOUSEFACILITY NUMBER:
198601684
ADMINISTRATOR:KIMBERLY LOZANOFACILITY TYPE:
734
ADDRESS:15255 LARKSPUR STREETTELEPHONE:
(818) 587-9450
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 5CENSUS: 5DATE:
08/11/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Amparo Purvin - AdministratorTIME COMPLETED:
01:00 PM
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A Required One (1) year visit was conducted today by Licensing Program Analysts (LPAs) Gary Tan and Mariana Agban. LPAs met with Administrator Amparo Purvin. Purpose of the visit was stated. LPA observed that the five (5) residents were at the facility during visit.

This facility is licensed as an Adult Residential Facility for Persons with Special Healthcare Needs (ARFPSHN) vendored by Northern Los Angeles Regional Center (NLARC) and Lanterman Regional Center (LRC).

A tour of the physical plant was conducted at 10:15 AM and the following was noted:

The main door is the only entrance being utilized at the facility. Screening area is located immediately upon entry. Sign in sheet, hand sanitizer, gloves and masks are available. LPAs were screened upon entry. All staff were observed to be wearing mask.

The facility had submitted and approved Mitigation plan and Infection Plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. All trash cans were observed to be with cover.

The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

(continued to LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VALLEY VILLAGE LARKSPUR HOUSE
FACILITY NUMBER: 198601684
VISIT DATE: 08/11/2023
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(continued from LIC 809)

LPAs toured the facility with the administrator. LPAs observed six (6) staff members (including the administrator) on duty providing care and supervision to the clients during today's visit. There are five (5) private bedrooms and all are equipped with a special lift installed to assist clients to transfer to/from their bed. All bedrooms were also observed to be fully furnished and maintained appropriately. There are two (2) bathrooms; both bathrooms were equipped with a special lift. The living room, dining area/activity room, kitchen area, medication area, laundry room, and garage were inspected and observed to be clean. Medications are kept in locked cabinet in the kitchen area. Cleaning supplies and other toxins were observed to be locked and inaccessible to clients. Clean linens were in adequate supply. Hot water was measured at a range of 114.6°F to 115.3°F.

Fire extinguishers. The facility has four (4) fire extinguishers which were last checked on 07/06/23. Carbon monoxide and smoke alarms are hardwired and interconnected, tested and observed to be operable. The facility is equipped with sprinkler system.
Garage is attached to the house and was observed to be locked and inaccessible to residents. The garage is also used as a storage for emergency supplies and perishable and emergency foods. There is a patio in the backyard area with outdoor furniture for residents' use. There is also a two (2) Van car port located in the front side yard. Outdoor area was also observed for safety. There was no body of water at the facility.
Client records were reviewed for current IPP’s and/or Needs and Service plans, physician report, admission agreements, etc. Residents' file appeared to be complete and updated.
Medication was observed to be inaccessible to residents and stored in a secured cabinet in the office area. Medication records and procedures reviewed with staff. There is a complete First Aid kit in the medication cabinet.
Staff records were reviewed. Staff present records were observed to be current and updated.

Disaster drill was last conducted on 08/01/23. Required posting are observed to be complete and current and displayed properly at the facility.

Exit interview was conducted and copy of this report was issued.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC809 (FAS) - (06/04)
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