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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604966
Report Date: 10/31/2022
Date Signed: 10/31/2022 12:27:09 PM

Document Has Been Signed on 10/31/2022 12:27 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: 6DATE:
10/31/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:55 AM
MET WITH:Matias BoncecesTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Tihesha Smith conducted an unannounced One (1) Year Required Infection Control visit for this facility at 9:55 am. LPA met with facility staff and explained the reason for this visit. LPA conducted a tour of the physical plant at 10:10 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

There are hand sanitizing stations all over the facility including signs to wear a mask and other Covid 19 prevention protocol signs were posted on entry door. The facility has a total of six (6) bedrooms and three (3) bathrooms. The rooms are designated as follows: Four (4) rooms for residents; one (1) room used as Covid Quarantine Room and one (1) room for staff. The bedrooms had adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets for residents’ comfort and safety.

There are two (2) bathrooms available for resident use. 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 two (2) bathrooms to ensure it is within the required range for residents’ comfort and safety. The water temperature range was between 123.5- and 122.9-degrees Fahrenheit.

Common areas were observed for the ability to safely serve the needs of residents. 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. LPA observed a sufficient supply of linens and toiletries in hall and living room closets.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The kitchen food supply was observed and sufficient for the four (4) residents currently residing there. Two (2) days of perishable fruits, vegetables, milk, and eggs observed. The freezer is stocked with meats, poultry, and frozen vegetables. Sharp objects are stored in a locked drawer. The resident’s medications and first aid kit are locked in kitchen cabinets next to table and window.

(Cont to 809 C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/31/2022
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORTHRIDGE GARDEN VILLA
FACILITY NUMBER: 197604966
VISIT DATE: 10/31/2022
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(Cont from 809)

Laundry room appliances observed to be functional. Toxins locked in laundry room cabinets observed to be locked and inaccessible to residents. Smoke alarms and carbon monoxide detectors were present and function properly. The fire extinguisher located near laundry room current with receipt attached.

There is a shaded area with furniture for residents’ use. A supply of PPEs stored in detached office/storage in back. Pool gate observed locked during today's visit.

No Deficiencies cited. Exit interview conducted and copy of report printed.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 10/31/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/31/2022
LIC809 (FAS) - (06/04)
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