197606498-4-24-2024-31-AS-NRED-D4MQSL-20240424122544

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197606498
Report Date: 04/24/2024
Date Signed: 04/24/2024 12:26:06 PM

Document Has Been Signed on 04/24/2024 12:26 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:	GEYSER HOME		FACILITY NUMBER:	197606498
ADMINISTRATOR/ DIRECTOR:	EDITHA C. TAGUM		FACILITY TYPE:	740
ADDRESS:	9539 GEYSER AVENUE		TELEPHONE:	(818) 718-0597
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6		CENSUS: 1	DATE:	04/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:35 AM
MET WITH:	Salvacion Tagum		TIME VISIT/ INSPECTION COMPLETED:	12:35 PM

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At 10:30 a.m on 04/24/2024, 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. LPA and staff toured the facility inside and out at 10:35 a.m.

The facility was last visited on 04/04/2022 for an annual inspection. It is a single-story building with six (06) bedrooms, three (03) bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for six (06) bedridden residents. The facility serves residents with dementia. Approved hospice waivers for two (02). Surveillance cameras used in common areas and the back yard.

At the main entrance, LPA observed a maintained front yard. Once inside, LPA was screened for infectious disease. The screening station contained a digital thermometer, hand sanitizer, and a visitor log. Postings were observed at the front for confidential complaint contacts, Ombudsman contacts, facility license, facility sketch, house rules, personal rights, emergency disaster plan, and activities.

The facility has six (06) bedrooms. One (01) bedroom 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. Bedroom #1 contained a resident with an oxygen machine and half-bed rails. A sign stating “No Smoking – Oxygen in use” was posted at the door. A sufficient supply of extra linens were located in a hallway storage area.

The facility has three (03) bathrooms. Resident bathrooms contained liquid soap, paper towels, handwashing instruction sign, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:45 a.m. LPA measured the water temperature in the southwest bathroom to be 105.0 degrees Fahrenheit.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

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: GEYSER HOME	FACILITY NUMBER: 197606498
	VISIT DATE: 04/24/2024

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Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:55 a.m. LPA measured the room temperature to be 70 degrees Fahrenheit. Board games, art supplies, television, reading material, and furniture in good repair were all observed in the living room. A fireplace was appropriately covered. At approximately 11:00 a.m., smoke and carbon monoxide detectors were tested and operational. Smoke detectors were hard-wired and functioned simultaneously when tested. LPA called the house telephone at 11:05 a.m. and verified it was working. At approximately 11:10 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 04/02/2024.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. The stove hood was clean. Appliances were in good condition. At 11:15 a.m. LPA measured the refrigerator and freezer temperatures to be 37 and 0 degrees Fahrenheit, respectively. Sharps and cleaning solutions were locked below the counter top. Medications were locked above the counter.

A washing machine and dryer were located in the garage. Both were in working order. The garage was locked and inaccessible to clients. It also contained emergency water supplies, assistive equipment, and other supplies.

LPA observed a covered patio area in the rear of the facility. The patio contained shaded furniture in good condition. The emergency exit paths were free from obstructions. The exit gate was unlocked. Auditory alarms were turned on and functioning. Fire sprinklers were observed throughout the home. The pool was surrounded by a gate and locked.

At 11:30 a.m. LPA conducted a record review of resident and personnel files.

During today's inspection, the facility was in compliance with Title 22 regulations. 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: 04/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/24/2024

LIC809 (FAS) - (06/04)

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