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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197602257
Report Date: 07/17/2023
Date Signed: 07/17/2023 03:44:22 PM

Document Has Been Signed on 07/17/2023 03:44 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:MARBLE TERRACE IIFACILITY NUMBER:
197602257
ADMINISTRATOR:GODLEWSKA, ELIZABETHFACILITY TYPE:
740
ADDRESS:19030 MIRANDA AVENUETELEPHONE:
(818) 345-8971
CITY:TARZANASTATE: CAZIP CODE:
91356
CAPACITY: 6CENSUS: 6DATE:
07/17/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Bozena KozbialTIME COMPLETED:
03:50 PM
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Licensing Program Analyst (LPA), Tihesha Smith conducted an unannounced Required 1-year inspection at this facility at approximately 9:45 am. LPA Smith was greeted by staff and disclosed the purpose of the visit. The administrator was contacted and arrived later.

LPA conducted a tour of the physical plant at approximately 10:25 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the kitchen, dining room area and living room. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be furnished appropriately.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the six (6) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen vegetables. Sharps are stored in two (2) locked kitchen drawers near stove. The resident medications are locked in office cabinets and locked in hallway closet/first aid kits. The medications were observed to be inaccessible to residents. There is one (1) fire extinguisher attached to wall in laundry area. Fire extinguisher observed to be charged.

Laundry room is in kitchen behind accordion style doors. The appliances observed to be functional. Toxins stored in locked cabinet above washer and dryer. Toxins observed to be locked and inaccessible to residents.

The facility has a total of six (6) bedrooms and four (4) bathrooms. There are five (5) bedrooms for residents and one (1) bedroom for staff and three (3) bathrooms for residents.
(Cont to 809C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/17/2023
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: MARBLE TERRACE II
FACILITY NUMBER: 197602257
VISIT DATE: 07/17/2023
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(Cont from 809)

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. LPA observed a supply of linens in closet next to Room#2 and #3.
Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured for the three (3) bathrooms to ensure it is
within the required range for residents’ comfort and safety. The water temperature range was: 107.2 , 109.3, and 113.2-degrees Fahrenheit.

Garage: is attached and used to store: one (1) Refrigerator with excess supply of meats and vegetables, PPEs, incontinent supplies, and storage for resident excess belongings.

Backyard has the following: Patio w/umbrella observed to have adequate seating. Patio furniture observed to be in good repair.

Smoke detectors/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards. There were no immediate health and safety hazard observed during the day of inspection.

At approximately 12:15 LPA reviewed Staff files for all six (6) staff. Staff training documents in a separate binder. Staff files had the appropriate training's to include Dementia training's, and First aid/CPR. Four (4) random Resident files included medical assessments, admission agreements, personal rights, individual program plan, DNR and two home health folders.

No deficiencies cited.

Exit Interview Conducted / A Copy of the Report Issued
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 07/17/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/17/2023
LIC809 (FAS) - (06/04)
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