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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609500
Report Date: 06/10/2024
Date Signed: 06/10/2024 01:44:43 PM

Document Has Been Signed on 06/10/2024 01:44 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:DEVONSHIRE ELDERLY CAREFACILITY NUMBER:
197609500
ADMINISTRATOR/
DIRECTOR:
BANGASH, FARAHFACILITY TYPE:
740
ADDRESS:17441 DEVONSHIRE STREETTELEPHONE:
(310) 955-0674
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 6DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:40 AM
MET WITH:Maria BangashTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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On 06/10/24, at 9:40 am., Licensing Program Analyst (LPA) Gina Saucedo arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met Caregiver, Saeeda Khan. Maria Bangash the designee administrator was called and arrived at 11:15 am. LPA asked for the census, resident, and staff files. The physical plant was toured inside and out at 10:25 am.

Living and dining room furniture is accessible for six (6) residents. There is a television and enough seating for six (6) residents. Furniture was observed to be in good condition. There is a fireplace in the living room area that has a covering. There is smoke detectors/carbon monoxide all over the house. The smoke detectors are hardwired and interconnected and were tested. There is one carbon monoxide against the wall at the entrance of the facility near the dining room area. They were functional. The facility temperature at 73 degrees Fahrenheit. There is one fire extinguisher that is dated January 2024. There is an extra/freezer refrigerator in the dining area. There is an Ombudsman, YES sign, Disaster/Evacuation Plan, Mitigation Plan, Theft and Loss, Facility sketch and administration certificate against the wall in the dining hall. There is internet and phone access in the dining hall.

Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. There is two (2) refrigerators in the kitchen area. The cabinets have canned goods. Sharps are kept secured and locked in one (1) of the cabinets on your left-hand side. The toxins are kept in the kitchen area in one (1) the cabinets locked and secured also inaccessible to residents on your left-hand side. The first aid kit is located in one of the bottom cabinets in the kitchen area.



Medication: The medication is kept in a cabinet area with resident files locked and secured inaccessible to residents in the living room area.

809C-continued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: DEVONSHIRE ELDERLY CARE
FACILITY NUMBER: 197609500
VISIT DATE: 06/10/2024
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Bedrooms: There are eight (8) bedrooms. Four (4) of the bedrooms is single, occupied. One (1) of the bedrooms is shared with a private bathroom. There are three (3) bedrooms upstairs for staff use only there. There is two (2) bathrooms upstairs and linen closets. All bedrooms were toured and were properly furnished and have appropriate bedding and linens. There are two (2) other bathrooms for resident use downstairs. The bathrooms have proper toiletry and grab bars. The bathroom temperatures of the water are within regulations reading at 115-119 degree Fahrenheit.

Outside/Backyard: There is a shed storage outside locked and secured with a washer and dryer. There is a huge backyard with a white fence. The outside/backyard has furniture for residents with proper seating. The facility has no signal system. The front of the house also has proper seating for the residents

Administrative: There is no annual fee that is due right now. The Insurance plan is updated as of 08/24/23-08/2024. At the entrance of the facility there is covid signs and PPE items, Oxygen in Use, No smoking.



An exit interview was conducted no citation(s) were issued and a copy of the signed report was given.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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