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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608511
Report Date: 07/23/2021
Date Signed: 07/23/2021 04:13:31 PM

Document Has Been Signed on 07/23/2021 04:13 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:CASA BLANCA HOMECAREFACILITY NUMBER:
197608511
ADMINISTRATOR:MARILOU A. ANDREASFACILITY TYPE:
740
ADDRESS:17216 GOYA STREETTELEPHONE:
(818) 366-2234
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 4CENSUS: 3DATE:
07/23/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:41 PM
MET WITH:Marilou Andreas - AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Gary Tan met with administrator Marilou Andreas for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit.

A tour of the physical plant was conducted at 1:50 PM and the following was noted:

There is only one entrance being utilized at the facility, there are required poster posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, Infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask upon entrance and during visit.

The facility had submitted and approved Mitigation plan.

Signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area at the backyard. The facility has sufficient stock of PPE in the storage room.

The facility has three (3) bedrooms and one (1) bathroom currently occupying three (3) residents. There are four (4) additional bedrooms and two (2) bathrooms upstairs designated for family and staff use. The facility is fire cleared for four (4) non-ambulatory residents one (1) of which may be bedridden in bedroom #1. Hospice waiver for two (2) residents.

(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/23/2021
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: CASA BLANCA HOMECARE
FACILITY NUMBER: 197608511
VISIT DATE: 07/23/2021
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(continued on LIC 809-C)

Living and dining room furniture were also checked. The living room is neat and clean along with the family room. The facility maintains a comfortable temperature at 75°F. The smoke detectors are hardwired and interconnected and observed to be operational.

The backyard of the facility has outdoor furniture, with a covered shaded area for clients. The swimming pool is appropriately fenced and observed clean.

The garage is attached to the home and currently being used as a laundry room, food and supplies storage. Cleaning solutions, laundry detergents and toxins are stored in the garage and was observed to be locked.

Food Service/Kitchen area was sufficiently stocked with two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Fire extinguisher is located at the kitchen and observed to be full and was last purchased on 01/02/2021



The Clients' rooms are adequately furnished with appropriate furniture and lighting system. Hall ways/passage ways are lit. Clients have sufficient amounts of personal hygiene product which is provided by the licensee.

Staff Rooms: Staff room is located upstairs and observed to be locked.

The bathroom was checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the toilet and shower. The hot water temperature was measured at 113.1°F. Towels and washcloths are not shared. There was enough clean linen available in stock at the cabinet.

Medications: LPA observed medication in the kitchen cabinet to be locked and inaccessible to residents. There are two (2) complete first aid kits located at the medication cabinet.

Exit interview conducted. Copy of this report issued
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
LIC809 (FAS) - (06/04)
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