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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604966
Report Date: 11/02/2021
Date Signed: 11/02/2021 12:47:15 PM

Document Has Been Signed on 11/02/2021 12:47 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 GARDEN VILLAFACILITY NUMBER:
197604966
ADMINISTRATOR:ANITA ORTIZFACILITY TYPE:
740
ADDRESS:10926 RESEDA BLVD.TELEPHONE:
(818) 360-1333
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY: 6CENSUS: 5DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:55 AM
MET WITH:Priscilla Bance ChcehapisanTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Wendell Smith conducted an unannounced annual required visit. LPA met with facility staff and explained the reason for this visit.
At approximately 11:05 am a physical plant tour was started the LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: Facility is a single story residence and consists of a total of six (6) bedrooms and three (3) bathrooms. Four (4) rooms are designated for resident use and two (2) are designated for staff use. Facility has dementia residents. All exit signal alarms were tested all exit alarms observed to be operable during visit. Smoke detectors and Carbon monoxide detector were tested and functioned properly during time of visit. Fire extinguishers were observed to be fully charged with services tag.
Kitchen: The kitchen appeared clean and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in a locked drawer. Cleaning supplies observed inaccessible locked up in the kitchen and laundry cabinets. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: All bathrooms observed properly supplied; with grab bars and non-skid mats installed.
Residents have sufficient amounts of supplies for personal hygiene. LPA measured the hot water in bathroom used by residents (in hallway) and observed water temperature to be 117 degrees F. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed furnished appropriately. Surrounding Grounds (Outdoors): There is a shaded area with furniture for outdoor use. Pool gate observed locked during today's visit. Storage rooms and garage observed in the backyard area.
SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Wendell Smith
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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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