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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850537
Report Date: 12/19/2024
Date Signed: 12/19/2024 12:16:33 PM

Document Has Been Signed on 12/19/2024 12:16 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:ALLIANCE HEALTH RCFE INCFACILITY NUMBER:
195850537
ADMINISTRATOR/
DIRECTOR:		GOLFEIZ, SARAFACILITY TYPE:
740
ADDRESS:23601 CANZONETTELEPHONE:
(818) 426-1136
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY: 6CENSUS: 6DATE:
12/19/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:30 AM
MET WITH:Sara GolfeizTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
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Licensing Program Analyst (LPA) Angela Barutyan conducted a pre-licensing visit to this property at 10:30AM. LPA met with applicant Sara Golfeiz. This application is for a Change of Ownership Application (CHOW) and the current licensed facility has residents in care. The applicant has obtained fire clearance for six (6) bedridden with a total capacity of six (6) residents. Applicant completed component II interview on 10/17/2024. During today's visit, applicant component III with the LPA.

Beginning at 10:33AM, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 11:40AM and function properly at this time. Fire extinguisher was observed to be fully charged and purchased on 10/19/2024. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living room, family room, and dining area are clean and properly furnished. A properly screened fireplace was observed in the family room. A working telephone is present.

The proposed facility has five (5) bedrooms of which four (4) are designated for private-resident use and one (1) is designated for shared-resident use. All resident bedrooms observed were furnished and contained beds, chairs, bedside tables, and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. The proposed facility has five (5) restrooms; four (4) are for resident-use and one (1) is for staff and visitor use. LPA observed night-lights present in the hallways. Hot water was measured in all five (5) restrooms and measured within the required range.

Report continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ALLIANCE HEALTH RCFE INC
FACILITY NUMBER: 195850537
VISIT DATE: 12/19/2024
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The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of emergency water. Knives were stored in a locked drawer. A locked medication cabinet was observed in the facility kitchen. First aid kit was observed and was complete. A locked garage was observed by the kitchen to contain extra storage space, cleaning supplies, additional refrigerator and freezer, as well as the laundry area.

Building and grounds were observed. Patio area contains a shaded seating area for resident use. Outdoor exit gate was observed to be self-closing and self-latching at this time. All passageways were observed to be clear of hazards.

Pre-Licensing is complete and this facility has no deficiencies.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted and a copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:

DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/19/2024
LIC809 (FAS) - (06/04)
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