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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197600961
Report Date: 09/30/2024
Date Signed: 09/30/2024 02:13:25 PM

Document Has Been Signed on 09/30/2024 02:13 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:NORTHRIDGE RETIREMENT VILLAFACILITY NUMBER:
197600961
ADMINISTRATOR/
DIRECTOR:		STEPHANIE FLORESFACILITY TYPE:
740
ADDRESS:18907 LIGGETT STREETTELEPHONE:
(818) 203-9411
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 5DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Aida AmanteTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. Upon arrival, LPA was greeted by staff and explained the reason for the visit. Shortly after, LPA met with Licensee Lani and Martin Manzano and explained the reason for the visit. Administrator, Aida Amante was also present during the annual inspection. At approximately 10:05 am, with the assistance of the Licensee, LPA took a tour of the physical plant, and the following were observed:

Required postings were observed in the entry area. The smoke alarms are interconnected and battery-operated. The smoke alarms and the carbon monoxide were tested and they were properly function.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The fire extinguisher is located in the kitchen with the purchase date 09/03/24.

Bedrooms: There were five (5) bedrooms in the facility. Four (4) are designated for residents' use and one (1) for staff use. Two (2) bedrooms are shared and two are private. All bedrooms were clean, properly furnished, and had sufficient lighting.
Bathrooms: There are two (2) bathrooms designated for residents' use. One (1) bathroom in the hallway which is the main,and one (1) in room #3. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 109.6 and 107.8 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.

Common Areas: These included the living room and dining area. The common areas were properly furnished. The dining room table is large enough to sit the capacity of the facility. Seating such as couches were in good repair and sit the capacity of the facility. The auditory alarms on all exit doors were on and functional at the time of the visit. (Continue on 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORTHRIDGE RETIREMENT VILLA
FACILITY NUMBER: 197600961
VISIT DATE: 09/30/2024
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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards.
Laundry Area: located through the kitchen. Appliances observed to be in good repair. Laundry detergents were locked inaccessible to residents. Garage: was observed to be only used for storage.
Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms.
Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliant with licensing forms.
Medications: Medication and Medication Records were reviewed for proper documentation.
Temperature: Facility maintains a comfortable temperature of 76 degrees Fahrenheit


Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
LIC809 (FAS) - (06/04)
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