<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609882
Report Date: 10/06/2021
Date Signed: 10/06/2021 01:25:59 PM

Document Has Been Signed on 10/06/2021 01:25 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:4TH GENERATION SENIOR LIVING INC.FACILITY NUMBER:
197609882
ADMINISTRATOR:AGGARWAL, RASHITAFACILITY TYPE:
740
ADDRESS:23259 VICTORY BLVDTELEPHONE:
(209) 505-7922
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 5DATE:
10/06/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:24 AM
MET WITH:Rashita Aggarwal/AdministratorTIME COMPLETED:
01:45 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Eleza Jackson and Licensing Program Analyst (LPA) Patrick Shanahan conducted an unannounced required annual. LPAs met with staff and explained the reason for this visit. LPAs were greeted by facility staff and after temperature checks were allowed to enter the facility.

The facility is a single-story building consisting of a living room, dining room, kitchen, 7 bedrooms (including one for staff), and 3 bathrooms.

LPAs inspected the clients' rooms, observing them to be clean and appropriately furnished. Bathrooms were sanitary and functional. The kitchen was clean and adequately supplied with perishable and non-perishable foods. Common areas were clean and appropriately furnished, as were outdoor common areas.

The home was checked for fire safety and observed that the smoke alarms, carbon monoxide detector and all door alarms appeared functioning properly.

The facility is following their approved mitigation plan and no deficiencies were cited on today's visit.

Exit interview conducted and report issued.



SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Eleza Jackson
LICENSING EVALUATOR SIGNATURE: DATE: 10/06/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/06/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 1