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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607629
Report Date: 12/22/2022
Date Signed: 12/22/2022 12:33:15 PM

Document Has Been Signed on 12/22/2022 12:33 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:RIDGEWOOD RESIDENTIAL CARE HOME #3FACILITY NUMBER:
197607629
ADMINISTRATOR:MARIA CRUZFACILITY TYPE:
740
ADDRESS:19231 DEARBORN STREETTELEPHONE:
(818) 626-9220
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 4CENSUS: 4DATE:
12/22/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
12:11 PM
MET WITH:Karla Plata TIME COMPLETED:
12:35 PM
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On 12/22/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct an unannounced case management incident visit. The purpose of the visit is to obtain additional information of the incident received by the regional office on 10/15/22. On 10/15/22 C1 had a warm cloth toweled applied to their left hand due to a bug bite and swelling. The cloth resulted in C1 obtaining a burn on the left hand. C1 was taken to urgent care to receive care.

LPA obtained C1's physician reports and discharge notes from hospital visit. LPA also collected doctor's notes from follow up visits. LPA measured the facility's hot water temperature and it measured at 113.3 F. Hot water is within regulations. On 10/25/22 Administrator requested the staff to receive first aid and CPR training. LPA obtain proof of completed training for all staff. LPA interviewed three staff that responded to the incident. Interviews revealed that S1 wet a cloth with warm water from the kitchen faucet. When the cloth was applied, C1 did not pull back indicating the towel was too hot. S1 stepped away to assist another client and when S1 returned to the living room within a couple of minutes S1 observed the cloth of the floor. According to S1, C1 did not seem to be distress or in pain. S1 then notice C1's hand was red and S1 immediately contacted the administrator and C1 was taken to urgent care.

No deficiency cited during todays visit. Exit interview conducted. Report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 12/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/22/2022
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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