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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197603012
Report Date:
10/07/2021
Date Signed:
10/07/2021 03:21:39 PM
Document Has Been Signed on
10/07/2021 03:21 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:
NORTHRIDGE RETIREMENT VILLA, LLC
FACILITY NUMBER:
197603012
ADMINISTRATOR:
LANI A. MANZANO
FACILITY TYPE:
740
ADDRESS:
18901 LIGGETT ST
TELEPHONE:
(818) 203-9411
CITY:
NORTHRIDGE
STATE:
CA
ZIP CODE:
91324
CAPACITY:
6
CENSUS:
6
DATE:
10/07/2021
TYPE OF VISIT:
Required - 1 Year
UNANNOUNCED
TIME BEGAN:
01:45 PM
MET WITH:
Lani Manzano, Aida Amante/co administrator
TIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Angelica Arambulo and Abeye Duguma conducted an unannounced required annual visit to the facility. Upon arrival the LPA were instructed to use the side door of the house. Entry through the gate was closed and the side screen door opens the opposite way from the steps so you had to take a two step entry to get onto the platform. Administrator Lani states it is so you can use the side bathroom and wash your hands before you enter. LPA's were screened with temperature taking and no questionaire or logging of temperatures.
Administrator certificates were valid and expires in 2022 for Lani Manzano. Certificate for Aida expires in 2023.
Mitigation plan is on file. LIC500 staff schedule needs to be updated. The register of residents is updated and posted. The LIC610E is updated and posted.
The screening questionaire was not being used and the staff was not taking their temperatures before and after a shift. Residents and visitor temperatures are taken once a day. The faciilty does have antigen testing on site. They will start surveillance testing for staff weekly.
The LPA did not observe any health or safety hazards during this visit. The report shall be emailed to facility email on file. Contact information shall be updated by LPA.
SUPERVISORS NAME
:
Eva Miller
LICENSING EVALUATOR NAME
:
Angelica Arambulo
LICENSING EVALUATOR SIGNATURE
:
DATE:
10/07/2021
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
10/07/2021
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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