197609340-9-27-2024-31-AS-NRED-D9HPZS-20240927114602

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609340
Report Date: 09/27/2024
Date Signed: 09/27/2024 11:46:21 AM

Document Has Been Signed on 09/27/2024 11:46 AM - 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	JACKIE'S HIDEAWAY A		FACILITY NUMBER:	197609340
ADMINISTRATOR/ DIRECTOR:	TAL, TALY		FACILITY TYPE:	740
ADDRESS:	5925 DONNA AVE		TELEPHONE:	(818) 345-6752
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY: 6		CENSUS: 5	DATE:	09/27/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:20 AM
MET WITH:	Andrie Alvarez		TIME VISIT/ INSPECTION COMPLETED:	11:55 AM

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tAt approximately 9:20 a.m. on 09/27/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with the administrator and disclosed the reason for the visit.
The facility was last visited on 09/20/22 for an annual visit. It is a single story building with six (06) bedrooms, five (05) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for six (06). Surveillance cameras are used in exterior areas.

The front entrance is gated and unlocked from the inside. The front yard is maintained. At the front door, LPA observed postings for the house rules, visitation policy, facility sketch, facility license, COVID precautions, rights of resident councils, ombudsman contacts, and oxygen in use signs. Additional postings were observed for the emergency disaster plan, personal rights, and administrator certificates. A screening station at the front contained a visitor log, sanitizer, and masks.

Walls, floors, windows, screens, and blinds were clean and in good repair. A fireplace was appropriately covered. At 9:30 a.m. LPA observed fully charged fire extinguishers in the kitchen and near the front entrance. They were purchased on 08/08/24. The living room contained a television, reading materials, and furniture in good repair. At 9:40 a.m. the house telephone was called and deemed operational. At 9:45 a.m. the carbon monoxide detector in the kitchen was tested and deemed operational. At 9:55 a.m. LPA observed a fully-stocked first aid kit in the kitchen. At 10:00 a.m. the house telephone was called and deemed operational.

Eight (08) out of eight (08) auditory alarms were on and functional. The seating area in the rear was shaded. The back yard also contained a gardened area. A storage shed was locked and contained tools and extra food supplies. Emergency exit paths were free of hazards. The exit gate was unlocked.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

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

FACILITY NAME: JACKIE'S HIDEAWAY A	FACILITY NUMBER: 197609340
	VISIT DATE: 09/27/2024

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LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerator, freezer, and pantry. Emergency food and water supplies were observed in the pantry. Appliances were in good condition. Sharps were locked below the counter top. Cleaning solutions were locked below the sink. Medications were locked above the counter top. The laundry area was near the kitchen and contained a washing machine and a dryer in working order. Detergents were locked above them in a cabinet. An office area near the laundry area contained locked confidential files.

The facility has six (06) bedrooms. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Exit doors from rooms were unlocked. The facility has five (05) bathrooms. Bathrooms contained liquid soap, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 10:25 a.m. LPA measured the water temperature to be 118.2 degrees Fahrenheit in the shared bathroom. At 10:30 a.m. LPA measured the room temperature to be 74 degrees Fahrenheit. At approximately 10:35 a.m., smoke detectors were tested and operational.

At 10:40 a.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit.

During today’s inspection, no immediate health or safety hazards were observed.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2024

LIC809 (FAS) - (06/04)

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