195850120-1-3-2025-29-AS-ABAN-DCKRL2-20250103120625

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850120
Report Date: 01/03/2025
Date Signed: 01/03/2025 12:06:50 PM

Document Has Been Signed on 01/03/2025 12:06 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:	ADVANCED HOME CARE SENIOR LIVING		FACILITY NUMBER:	195850120
ADMINISTRATOR/ DIRECTOR:	SANTOS, CATHERINE		FACILITY TYPE:	740
ADDRESS:	5826 JUMILLA AVE		TELEPHONE:	(818) 340-4652
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 6	DATE:	01/03/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:06 AM
MET WITH:	Catherine Santos, Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 10:06AM. LPA was greeted at the door by staff and the reason for the visit was explained. Administrator Catherine Santos arrived at the facility at 10:45AM. Entrance interview conducted.

At 10:08AM, the LPA along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

BEDROOMS: There are six (6) bedrooms total of which four (4) are for single resident-use, one (1) is for shared resident-use, and one (1) is for staff-use. LPA observed resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Staff room was observed locked.

RESTROOMS: There are four (4) restrooms of which two (2) are shared between resident rooms and two (2) are in the hallway. Restrooms were clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The restrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. Between 10:14AM – 10:16AM, hot water temperatures were measured in resident restrooms and were between 111.4 degrees F – 116.3 degrees F, which is within the required range.

KITCHEN: The LPA inspected the kitchen/food service area at 10:19AM. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for expiration dates and food labels had expiration date clearly marked. Knives and chemicals were locked inaccessible in kitchen drawer and cabinet. Fire extinguishers were fully charged and last serviced 08/12/2024.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ADVANCED HOME CARE SENIOR LIVING	FACILITY NUMBER: 195850120
	VISIT DATE: 01/03/2025

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COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. The facility maintained a comfortable temperature. At 10:30AM, smoke detector(s) and carbon monoxide detector tested and were operational at the time of the visit. Auditory exit alarms were functioning at the time of the visit. LPA observed required postings throughout the common spaces.

OUTDOOR AREA: At 10:22AM, LPA observed the back and front patio which has a covered outdoor area for resident use. There is a gate on the side of the house designated for an emergency exit. The property is gated. Passageways were free and clear from obstruction. There are no bodies of water on the premises. There are two (2) locked storage sheds. The property has an ADU behind the facility.

RECORD REVIEW: Beginning at 10:31AM, LPA reviewed six (6) out of six (6) resident files and four (4) personnel files for documents including but not limited to: medical records, care plans, resident Admission Agreement, TB test, health screening, staff training and fingerprint clearance. All resident and personnel files were in order. During the visit, LPA obtained copies of valid liability insurance, LIC 500, and resident roster.

MEDICATION REVIEW: At 11:47AM, LPA reviewed medications for three (3) residents. Medications are centrally stored and locked in the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency drills are conducted quarterly as is required, with the last drill conducted on 11/12/2024.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 01/03/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/03/2025

LIC809 (FAS) - (06/04)

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