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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850281
Report Date: 11/28/2023
Date Signed: 11/28/2023 04:27:56 PM


Document Has Been Signed on 11/28/2023 04:27 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:NAVITA RESIDENCES TULLFACILITY NUMBER:
565850281
ADMINISTRATOR:VIJAYAKUMAR, KARTHIGAFACILITY TYPE:
740
ADDRESS:5603 TULL STTELEPHONE:
(805) 494-4121
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY:6CENSUS: 6DATE:
11/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:45 PM
MET WITH:Karthiga VijayakumarTIME COMPLETED:
04:40 PM
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Licensing Program Analyst (LPA) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 2:45 p.m. When the LPA arrived, there was two staff and six residents present. The LPA was greeted by Caregiver Emma Cacho and informed them of the reason for the visit. Administrator Karthiga Vijayakumar shortly arrived.

At 02:54 p.m. the LPA conducted a tour of the physical plant with the Administrator. The following was noted: Facility is a single-story residence that consists of six (6) resident bedrooms and three (3) bathrooms. There is one (1) additional bedroom for staff use. LPA observed (1) fully charged fire extinguisher purchased in March of 2023. All smoke alarms and carbon monoxide detectors were tested and functioned properly during the time of visit. The LPA observed all required postings in the hallway. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. The LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked cabinet.
Bedrooms: The resident bedrooms were properly furnished with at least one chair, nightstand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.
Bathrooms: LPA observed all bathrooms clean, properly supplied and had functional fixtures. The LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured in the communal bathroom during physical plant tour. Hot water measured 105.6 degrees Fahrenheit, within the required limit of 105-120 degrees Fahrenheit.

Report will continue on LIC809-C.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/28/2023
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NAVITA RESIDENCES TULL
FACILITY NUMBER: 565850281
VISIT DATE: 11/28/2023
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Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. There is a fireplace in the living room, which is covered with a screen. The facility maintained a comfortable temperature of 76 degrees.

Garage/Laundry room: The facility has a laundry room where the washer and dryer are held. The laundry room leads to the garage where cleaning supplies and disinfectants are kept, and additional PPE supplies are stored. The Garage remains locked and inaccessible to the residents in care.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

Interviews: During the facility tour the LPA conducted two (2) resident Interviews. At 3:23 p.m. the LPA conducted two (2) staff interviews. No immediate concerns were voiced.

Due to time constraints the LPA will return to complete annual at a later date. Copy of Licensing Report provided to Administrator.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:

DATE: 11/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/28/2023
LIC809 (FAS) - (06/04)
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