197608615-11-8-2023-31-AS-LNCA-CXDTUD-20231108140209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608615
Report Date: 11/08/2023
Date Signed: 11/08/2023 02:02:14 PM

Document Has Been Signed on 11/08/2023 02:02 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BLUE RIDGE HOME CARE		FACILITY NUMBER:	197608615
ADMINISTRATOR:	KARLA B. PLATA		FACILITY TYPE:	740
ADDRESS:	16604 LASSEN STREET		TELEPHONE:	(818) 892-2184
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 6	DATE:	11/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Bernarda Tobias and Antonio Capistrano		TIME COMPLETED:	02:30 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) Leslie Ngo-Castaneda and Gina Saucedo conducted an annual required visit and inspection of the facility. LPAs met with staff, Bernarda Tobias and Antonio Capistrano and explained the reason for the visit. Approximately, around 9:45am administrator Karla Plata and after an hour around 10:30am the licensee Maria Rowena Cruz arrived. At 9:30 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 6/8/2023. During the visit the facility is at 75 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatories of which one (01) may be bedridden. Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPAs found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked cabinet in the kitchen. Office space is in the dining area beside the kitchen where staff has a separate dining table from the residents. Properly labeled medications were locked in the dining area cabinets in the office station. Bedrooms: There were six (6) bedrooms designated for residents' use. Four of the bedrooms, in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Room #2 and #4 are properly furnished and occupied by only one (1) resident. Room #1 and #3 is shared room with two (2) resident occupants. The upstairs (2^nd) floor is only for staff bedroom and staff bathroom that is locked with no medication in sight. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE RIDGE HOME CARE	FACILITY NUMBER: 197608615
	VISIT DATE: 11/08/2023

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

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 109.4 degrees Fahrenheit for bathroom #1 located in the hallway beside room #1. Bathroom #2 measured 108.3 degrees Fahrenheit in room #4 bedroom. Cleaning supplies are being stored in a locked cabinet in the laundry room. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Residents dining table fits enough for six (6).

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area and detergents are located by the laundry room at the end of the hallway in between room #2 and room #1 that are kept secured. The facility does not have a swimming pool or body of water. The garage is detached and is used for parking and storage for incontinence for residents and staff refrigerator.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records (MMR) were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit interview conducted and a copy of the report issued.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 11/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/08/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2