197602257-2-5-2025-31-AS-NRED-DDLTBT-20250205133541

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602257
Report Date: 02/05/2025
Date Signed: 02/05/2025 01:36:27 PM

Document Has Been Signed on 02/05/2025 01:36 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	MARBLE TERRACE II		FACILITY NUMBER:	197602257
ADMINISTRATOR/ DIRECTOR:	GODLEWSKA, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	19030 MIRANDA AVENUE		TELEPHONE:	(818) 345-8971
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY: 6		CENSUS: 5	DATE:	02/05/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Bozena Kozbial		TIME VISIT/ INSPECTION COMPLETED:	01:45 PM

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At approximately 10:00 a.m. on 02/05/2025, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and later the administrator and disclosed the reason for the visit.

A file review was conducted prior to the visit.

The facility was last visited on 02/14/2024 for an annual inspection. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents. Approved hospice waivers for one (01).

At 10:20 a.m., LPA reviewed resident and personnel files. All files were complete and available for audit. Additionally, LPA reviewed the updated certificate of liability insurance.

At the main entrance, LPA observed a maintained front yard with stairs leading to the main entrance. The driveway was free of debris. Postings were observed for confidential complaint contacts, ombudsman contacts, personal rights, rights of resident councils, nondiscrimination notice, neighborhood grievance procedure, emergency disaster plan, facility license, facility sketch, administrator certificate, and a blank copy of an admission agreement. Signs showing “No smoking – Oxygen in use” were posted at the main entrance and applicable rooms.

The facility has six (06) bedrooms. Bedroom #6 is designated as a staff room. The staff room was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. All beds with wheels were maintained in the locked position as a fall precaution. A cosmetic repair is needed in Bedroom #5 to cover the hole left from removing the old smoke alarm. A Technical Violation is issued on the corresponding LIC 9102-TV to repair the hole.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: MARBLE TERRACE II	FACILITY NUMBER: 197602257
	VISIT DATE: 02/05/2025

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The facility has four (04) bathrooms. One (01) bathroom is designated for staff, and three (03) others are shared for residents. All bathrooms contained liquid soap, paper towels, trash cans, grab bars near the toilet and shower, and a non-skid mat or non-skid surfaces in the showers. At 11:25 a.m. LPA measured the water temperature in the bathroom near Bedroom #5 to be 115.7 degrees Fahrenheit. At approximately 11:45 a.m., smoke and carbon monoxide detectors were tested and operational. Smoke alarms are hard-wired and functioned simultaneously.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator and freezer and the garage refrigerator and freezer. A pantry near Bedroom #3 contained additional non-perishable food supplies. The stove hood was clean. Appliances were in good condition. Sharps were locked below the stove. Cleaning solutions were locked below the sink. A washing machine and dryer were located adjacent to the kitchen. Both were in working order. Detergents were locked above the washer.

Walls, floors, windows, screens, and blinds were clean and in good repair. The living room contained furniture in good repair, reading material, and exercise equipment. An office was locked and contained confidential files and medications. A linen closet near Bedroom #4 contained an adequate supply of fresh linens, PPE, and hygiene supplies. A locked closet nearby contained decorations and tools. Seven (07) out of seven (07) auditory alarms were tested and functional. LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition.

All emergency exit paths were free from obstructions. Two (02) out of two (02) exit gates were unlocked. At approximately 12:45 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 05/16/2024. The garage was unlocked and free of hazards. The house telephone was called at 12:50 p.m. and was deemed operational.

During today’s inspection, no immediate health and safety risks were observed.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 02/05/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2025

LIC809 (FAS) - (06/04)

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