<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197604966
Report Date: 12/09/2024
Date Signed: 12/09/2024 03:36:51 PM

Document Has Been Signed on 12/09/2024 03:36 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:NORTHRIDGE GARDEN VILLAFACILITY NUMBER:
197604966
ADMINISTRATOR/
DIRECTOR:
ANITA ORTIZFACILITY TYPE:
740
ADDRESS:10926 RESEDA BLVD.TELEPHONE:
(818) 360-1333
CITY:NORTHRIDGESTATE: CAZIP CODE:
91326
CAPACITY: 6CENSUS: 6DATE:
12/09/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Anita OrtizTIME VISIT/
INSPECTION COMPLETED:
02:20 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff and explained the reason for the visit. Administrator, Anita Ortiz was contacted and arrived shortly after.

At approximately 10:15 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area.

Common Areas: The common areas were properly furnished. The auditory alarms on all exit doors were on and functional during the visit. The dining room table is large enough to accommodate the facility's capacity. Seating such as couches were in good repair and sat the capacity of the facility. The living room has televisions and comfortable furniture. LPA observed the fire extinguisher with a purchase date of 08/19/2024. Fire alarm and carbon monoxide function properly. Bedrooms: There were four(4) bedrooms designated for residents' use and two (2) bedrooms designated for staff. All bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three (3) bathrooms designated for residents' use. All bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 112.8 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Laundry Area: located through the kitchen. Appliances were observed to be in good repair. Laundry detergents were locked in a cabinet and thus toxins were inaccessible to residents. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. There is a swimming pool that is fenced all around its parameters. The fence was at least five feet high with a gate, that was also five feet high. The gate was observed locked, making it inaccessible for residents to enter. Resident Files: LPA conducted a file review of resident records to ensure compliance with licensing forms. (Continue on 809C)
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: NORTHRIDGE GARDEN VILLA
FACILITY NUMBER: 197604966
VISIT DATE: 12/09/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing forms. Medications: Medication and Medication Records were reviewed for proper documentation. Temperature: Facility maintains a comfortable temperature of 75 degrees Fahrenheit.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:

DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2