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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609791
Report Date: 09/15/2024
Date Signed: 09/15/2024 04:23:27 PM

Document Has Been Signed on 09/15/2024 04:23 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:ATWATER VILLAGE SOUTHFACILITY NUMBER:
197609791
ADMINISTRATOR/
DIRECTOR:		ESPIRITU, JOCELYNFACILITY TYPE:
740
ADDRESS:3454 PERLITA AVETELEPHONE:
(323) 665-6893
CITY:LOS ANGELESSTATE: CAZIP CODE:
90039
CAPACITY: 6CENSUS: 6DATE:
09/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:00 PM
MET WITH:Christopher EspirituTIME VISIT/
INSPECTION COMPLETED:
04:35 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Christopher Espiritu for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 1:00 PM and the following was noted:

There is one entrance being utilized at the facility. The facility has a total of four (04) bedrooms and two (02) bathrooms. The facility is fire cleared for six (06) non-ambulatory, of which one (01) may be bedridden, and a hospice waiver for four (04). The facility is currently occupying six (06) residents.

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. Laundry detergents, cleaning agents and other toxins are locked away.

Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

The living and dining room are neat and clean. The facility maintains a comfortable temperature at 73°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the front entrance, observed to be fully charged and last inspected on 11/20/2023.

(continued on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 09/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/15/2024
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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ATWATER VILLAGE SOUTH
FACILITY NUMBER: 197609791
VISIT DATE: 09/15/2024
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The residents' rooms are adequately furnished with appropriate lighting system. Hallways 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 117.8°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 09/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/15/2024
LIC809 (FAS) - (06/04)
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