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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608663
Report Date: 02/22/2022
Date Signed: 02/22/2022 08:38:06 PM

Document Has Been Signed on 02/22/2022 08:38 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:CEDARCREEK MANORFACILITY NUMBER:
197608663
ADMINISTRATOR:RICHARD K. GORDONFACILITY TYPE:
740
ADDRESS:27126 LANGSIDE AVENUETELEPHONE:
(818) 269-2230
CITY:SANTA CLARITASTATE: CAZIP CODE:
91351
CAPACITY: 6CENSUS: DATE:
02/22/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:56 PM
MET WITH:Angelito GomezTIME COMPLETED:
04:39 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with, Angelito Gomez, 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 2:00pm and the following was noted:
There is one entrance being utilized at the facility, there are required posters 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 masks upon entrance and during the visit. Signs to wear masks 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 outdoor visitors' area located in front of the building. The facility has sufficient stock of PPE in a storage cabinet located in the garage. The facility has a total of five (05) bedrooms of which four (04) are for residents and two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) bedridden and a hospice. The facility is currently occupying four (04) non-ambulatory residents and two (02) under hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. The garage is being used for office, storage and laundry. Laundry detergents, cleaning agents and other toxins are stored in a locked cabinet in the garage. Food Service/Kitchen area was sufficiently stocked with at least 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.
(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/22/2022
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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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: CEDARCREEK MANOR
FACILITY NUMBER: 197608663
VISIT DATE: 02/22/2022
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Knives and sharps are observed to be locked in a locked drawer inaccessible to residents. Living/common and dining room furniture were also checked. The living/common room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 72°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located in the kitchen, observed to be full and last inspected on 08/13/2021. Staff rooms were observed to be locked and located near the kitchen area. No medications are observed in the staff room. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 109.2°F. Towels and washcloths are not shared. There was enough clean linen available in the coat closet. LPA observed medication and first-aid kit to be locked and inaccessible to residents in the storage closet.

Exit interview conducted. Copy of this report issued.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2022
LIC809 (FAS) - (06/04)
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