191290719-2-27-2025-31-AS-NSHN-DEB3J4-20250227171654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191290719
Report Date: 02/27/2025
Date Signed: 02/27/2025 05:17:07 PM

Document Has Been Signed on 02/27/2025 05:17 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:	MOTHER GERTRUDE HOME		FACILITY NUMBER:	191290719
ADMINISTRATOR/ DIRECTOR:	SR. ELIA CARO		FACILITY TYPE:	740
ADDRESS:	11320 LAUREL CANYON BLVD		TELEPHONE:	(818) 898-1546
CITY:	SAN FERNANDO	STATE: CA	ZIP CODE:	91340
CAPACITY: 97		CENSUS: 28	DATE:	02/27/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Sister Elia Caro - Administrator		TIME VISIT/ INSPECTION COMPLETED:	04:36 PM

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Licensing Program Analyst (LPA) Nadia Shahbazian conducted an unannounced annual required visit and met with Sister Elia Caro - Administrator at 9:15 am. LPAs explained the purpose of today’s visit. The facility has an approved fire clearance for thirty six (36) non-ambulatory and sixty one (61) ambulatory elderly adults 60 years old and above. Current census is twenty eight (28).

The facility is a two-story structure consisting of the following: Thirty three (33) resident room suites with private bathrooms, public restrooms, staff rooms, administrative office and staff meeting room, lobby, a chapel, an activity room, a dining area, a kitchen, a laundry, medication room and exterior courtyards. Physical building structure was observed to be in good conditioned with nicely maintained landscaping.

LPA observed required postings at the front entrance, lobby and office areas. Positing included but were not limited to: Facility license, ombudsman contacts, emergency disaster plan, rights of resident councils, personal rights and the facility sketch.

(Continued on 809-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

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: MOTHER GERTRUDE HOME	FACILITY NUMBER: 191290719
	VISIT DATE: 02/27/2025

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At 10:25 am LPAs and administrator toured the physical plant. Fire sprinklers were located throughout the facility on both floors, including resident rooms. LPAs observed several fully charged throughout each floor. Fire extinguishers, smoke detectors/mono-oxide carbon detectors were all inspected by the Fire Department on 12/27/2024. Facility conducts quarterly disaster drills. The last Fire/Disaster Drills was conducted on 12/05/2024 .

Resident rooms were randomly inspected for health and safety in both floors. Bedrooms were observed to have cabinets, dresser drawers, beds, chairs and adequate lighting. Bedrooms were clean and supplied with ample mattress, bedding/linens. LPAs observed that a signal system is activated by a pull cord in each bathroom and bedroom. The signal system was tested in resident room 102A at 11:05 and in room 212B at 11:23 In each instance staff responded to the signal within 2-3 minutes. Each bedroom has it's own bathroom. LPAs ensured that grab bars were properly installed in bathrooms and showers had non-skid mats. Bathrooms were clean and operational. Water temperature was measured at multiple rooms in both floors, ranging between 106.6 – 117.4 degrees Fahrenheit.

Kitchen: The facility has a commercial kitchen area that is equipped with two (2) commercial refrigerators, one (1) walking refrigerator, freezer, stove/oven, microwave oven and sink. LPA also observed two (2) walking pantries. There was an adequate supply of non-perishable food items observed (7 days) and (2 days) of perishable supplies.

Medications: LPA observed that medications were locked in the Medication Room with proper labels for each resident.

(Continued on 809-C)

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

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: MOTHER GERTRUDE HOME	FACILITY NUMBER: 191290719
	VISIT DATE: 02/27/2025

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Laundry Room: LPA observed two (2) regular size washing machines and two (2) regular dryers, two (2) commercial sized washers and two (2) commercial dryers in the laundry room. Detergents and cleaning supplies were locked near the appliances.

LPA toured the patio area and backyard. Entry/exit gates and pathways were free of obstruction. There were several exit doors throughout the facility. A raised fountain was observed in the patio area. There is ample patio space for outdoor activities. There were appropriate furniture, including chairs, benches, tables, umbrellas and three (3) swings for outdoor use, sufficient for number of residents.

Due to time constraints, LPA will need to return to facility to review staff and resident records on a different date.

A Copy of the Report provided to Administrator

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Nadia Shahbazian
LICENSING EVALUATOR SIGNATURE:	DATE: 02/27/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2025

LIC809 (FAS) - (06/04)

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