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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609767
Report Date: 11/04/2024
Date Signed: 11/05/2024 08:00:46 AM

Document Has Been Signed on 11/05/2024 08:00 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ASSURE CARE VILLAFACILITY NUMBER:
197609767
ADMINISTRATOR/
DIRECTOR:		PEREGRINO, FLORENCEFACILITY TYPE:
740
ADDRESS:8854 OAKDALE AVETELEPHONE:
(747) 237-2345
CITY:NORTHRIDGESTATE: CAZIP CODE:
91324
CAPACITY: 6CENSUS: 5DATE:
11/04/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Florence PeregrinoTIME VISIT/
INSPECTION COMPLETED:
02:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA met with staff 1 (S1) and explained the reason for the visit. Administrator, Florence Peregrino had arrived shortly after. At approximately 10:15 am, with the assistance of staff 1 (S1), LPA took a tour of the physical plant. Required postings were observed in the entry area.
Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. The laundry area is located through the kitchen. The washer and dryer were observed to be in good condition. Bedrooms: There were five (5) bedrooms designated for residents' use. Four (4) bedrooms are designated for private use, and one (1) room is shared. All five bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There were four (4) bathrooms in the facility. One (1) bathroom in hallway and three (3) bathrooms in the private bedrooms. All bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was 115.6 degrees Fahrenheit. Cleaning supplies were kept in locked cabinets. Temperature: Facility maintains a comfortable temperature of 78 degrees Fahrenheit. Smoke Alarms and Carbon Monoxide: detectors were tested and function properly. Fire extinguisher is located in the kitchen with purchase date 11/4/24. Common Areas: These included the living room and dining area. The common areas were properly furnished with adequate couches, chair, and television. The dining area had a large table, to seat up to six (6) individuals. Furniture in common areas were clean and in good repair. Floors were mopped and clean. Hallways and passageways were clear of any obstruction. Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. No lock on the side gate. There was furniture appropriate for outdoor use. The backyard has sufficient space to hold outdoor activities. There are no pools or any other bodies of water. Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms. Staff Files: LPA was unable to conduct staff file review as there was no physical file for S1, S2 and S3. Medications: Medication and Medication Records were review for proper documentation. Exit interview conducted, citation issued and copy of this report signed and delivered.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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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Document Has Been Signed on 11/05/2024 08:00 AM - It Cannot Be Edited


Created By: Mariana Agban On 11/04/2024 at 02:04 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ASSURE CARE VILLA
FACILITY NUMBER: 197609767

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/04/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interviews, the licensee did not comply with the section cited above. S1, S2 and S3 have no physical file in the facility which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 11/22/2024
Plan of Correction
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Administrator will submit S1, S2 and S3 physical file via email to the LPA by the POC date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Mariana Agban
LICENSING EVALUATOR SIGNATURE:
DATE: 11/04/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/04/2024


LIC809 (FAS) - (06/04)
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