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

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606784
Report Date: 09/12/2022
Date Signed: 09/12/2022 02:23:51 PM

Document Has Been Signed on 09/12/2022 02:23 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:HERITAGE OF NORTHRIDGEFACILITY NUMBER:
197606784
ADMINISTRATOR:MIJARES, MARYANNFACILITY TYPE:
740
ADDRESS:19251 CALAHAN STREETTELEPHONE:
(818) 775-9806
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 3DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:25 PM
MET WITH:Maryann MijaresTIME COMPLETED:
02:35 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
On 9/12/22 at 1:30 p.m. Licensing Program Analyst (LPA) Melissa Ruiz arrived at the facility to conduct an unannounced annual inspection. Upon arrival, LPA was greeted by Administrator Maryann. LPA observed covid-19 signage, hand sanitizer, PPE supplies and a visitor sign in log. LPA reminded Administrator to conduct infection control protocols for every visitor. LPAs temperature was taken and a visitors log was used. LPA observed PPE supplies and hand sanitizer. LPA explained to the Administrator the purpose of the visit and an entrance interview was conducted.

LPA initiated a physical plant tour at 1:40 p.m. Facility is a Residential Care Facility for the Elderly which was licensed for six (6) non-ambulatory, of which one (1) may be bedridden. Facility has been approved for a hospice waiver for one (1).

LPA was able to tour the facility and did not observe any immediate health and safety concerns. Sufficient PPE supplies were observed. The fire extinguisher was observed and has a date of service of 3/14/22. Smoke detectors and carbon monoxide monitors were observed to be functional. Facility maintains a comfortable temperature of 76 degrees Fahrenheit. LPA observed there to be sufficient stock of one-week non-perishable foods and two day perishable foods. Sharps, cleaning supplies and medications are centrally stored and are kept locked in various kitchen cabinets and drawers. Bedrooms are appropriately furnished and have appropriate lighting. Bathrooms have soap, paper towels and hand washing signs were observed. Extra towels and linens were readily available. There is a clean covered shaded area in the back yard and there are no bodies of water.

No deficiencies issued during today’s visit. Report was signed and delivered by Administrator and an exit interview was conducted.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Melissa Ruiz
LICENSING EVALUATOR SIGNATURE: DATE: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/12/2022
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 1