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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608663
Report Date: 06/07/2022
Date Signed: 06/07/2022 12:26:24 PM

Document Has Been Signed on 06/07/2022 12:26 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: 5DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:36 AM
MET WITH:Elsie GomezTIME COMPLETED:
12:24 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with staff, Elsie 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 9:30am and the following was noted:
There is one entrance being utilized at the facility. 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 throughout the facility. The facility has sufficient stock of PPE. The facility has a total of six (06) bedrooms of which five (05) are for residents and three (03) bathrooms for both residents and staff. The facility is fire cleared for six (06) bedridden. The facility is currently occupying five (05) residents of which one (01) is bedridden. The facility has outdoor furniture, with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. The garage is being used for 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. 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 room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 78°F.
(continued on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
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: 06/07/2022
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The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. The facility has a fire sprinkler system. Fire extinguisher is located in the kitchen, observed to be full and last inspected on 08/13/2021. 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 115.2°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway closet. LPA observed medication to be locked and inaccessible to residents in the storage (coat) closet.

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

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
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