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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609816
Report Date: 02/11/2022
Date Signed: 02/11/2022 04:24:40 PM

Document Has Been Signed on 02/11/2022 04:24 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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:STANSBURY PLACE INCFACILITY NUMBER:
197609816
ADMINISTRATOR:SHINN, MARIA ELENAFACILITY TYPE:
740
ADDRESS:8425 STANSBURY AVETELEPHONE:
(818) 924-7165
CITY:PANORAMA CITYSTATE: CAZIP CODE:
91402
CAPACITY: 5CENSUS: 5DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:40 PM
MET WITH:Joshua Smith, LicenseeTIME COMPLETED:
04:25 PM
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Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit at 2:40 p.m. LPA was greeted and screened by Licensee Joshua Smith. This annual had a specific emphasis on infection control practices and procedures.

At 3:08 p.m. LPA and Licensee began the physical plant tour inside and outside to ensure there are no health and safety hazards and facility is in compliance with the Title 22 Regulations.

COMMON AREAS: At 2:42 p.m., LPA observed common areas to be relatively clean and properly furnished. Required signs such as the license and complaint poster are posted near the front entrance. Signs are posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing. LPA observed activities and board games in the living area. LPA observed the fire extinguisher to be fully charged and purchased on 06/08/2021.

KITCHEN: At 3:09 p.m., LPA observed the kitchen/dining area. Knives are stored in the locked kitchen cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 3:12 p.m., kitchen hot water temperature measured at 109.2-degree Fahrenheit. Medications are located in a locked cabinet near the kitchen area. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in a kitchen cabinet. The laundry area is near the kitchen area.

BEDROOMS: At 3:14 p.m., LPA observed multiple resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Passageways were free and clear from obstruction. Inside temperature was maintained at a comfortable level.

Continued on LIC 809C.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/11/2022
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: STANSBURY PLACE INC
FACILITY NUMBER: 197609816
VISIT DATE: 02/11/2022
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Contiued from LIC 809.

RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skids mats. At 3:15 p.m., LPA observed hot water to be measured at 106.5-degree Fahrenheit.

OUTDOOR SPACE: At 3:18 p.m., LPA observed the front and backyard which has a covered outdoor area for resident use. The facility has a two (2) side gates with a latch for emergency exits.

INFECTION CONTROL: During today’s visit, the LPA spoke with Licensee regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.

The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

Between 2:52 p.m. – 3:08 p.m., LPA conducted Infection Control mitigation module with Licensee.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/11/2022
LIC809 (FAS) - (06/04)
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