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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609882
Report Date: 09/28/2024
Date Signed: 09/28/2024 03:02:13 PM

Document Has Been Signed on 09/28/2024 03:02 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:4TH GENERATION SENIOR LIVING INC.FACILITY NUMBER:
197609882
ADMINISTRATOR/
DIRECTOR:		AGGARWAL, RASHITAFACILITY TYPE:
740
ADDRESS:23259 VICTORY BLVDTELEPHONE:
(747) 226-0923
CITY:WEST HILLSSTATE: CAZIP CODE:
91307
CAPACITY: 6CENSUS: 5DATE:
09/28/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:20 PM
MET WITH:Rashita AggarwalTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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At approximately 12:20 p.m. on 09/28/24 Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with staff and later the administrator and disclosed the reason for the visit.

The facility was last visited on 09/21/22 for an annual visit. It is a single story building with seven (07) bedrooms, three (03) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for five (05). Surveillance cameras are used in common areas.

The front entrance is gated and unlocked. The front yard is maintained and free of hazards. At the front door, LPA observed postings for the house rules, visitation policy, facility sketch, facility license, COVID precautions, rights of resident councils, personal rights, ombudsman contacts, emergency disaster plan, personal rights, and administrator certificates. A screening station at the front contained a visitor log, sanitizer, digital thermometer, and masks.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 12:30 p.m. LPA measured the room temperature to be 73 degrees Fahrenheit. The living room contained a television, reading materials, and furniture in good repair. Activities were set up on the dining room table. Hallway closets contained adequate supplies of fresh linens and extra supplies. A locked closet contained confidential files, medications, and a fully-stocked first aid kit. At 12:40 p.m. the house telephone was called and deemed operational. LPA observed an adequate supply of perishable and non-perishable foods in the kitchen refrigerators, freezers, and pantry. Appliances were clean and in good condition. Sharps were locked below the counter top. Cleaning solutions and detergents were locked in the laundry area adjacent to the kitchen. The laundry area contained a washing machine and a dryer in working order.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2024
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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: 4TH GENERATION SENIOR LIVING INC.
FACILITY NUMBER: 197609882
VISIT DATE: 09/28/2024
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At 12:50 p.m. the combination carbon monoxide and smoke detectors were tested and operational. At 12:55 p.m. a fully-charged fire extinguisher was observed in the kitchen. All auditory alarms were on and functional. Two (02) seating areas in the rear were shaded with furniture in good repair. The back yard also contained a gardened area, exercise equipment, and a gas grill. The garage was locked and contained tools and extra supplies. Emergency exit paths were free of hazards. The exit gate was unlocked.

The facility has seven (07) bedrooms. One (01) bedrooms served as a staff room. The staff room was free of hazards. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Exit doors from rooms were unlocked.

The facility has three (03) bathrooms. Two (02) bathrooms are private, and one (01) is shared. Bathrooms contained liquid soap, trash cans with tight fitting lids, bidets, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 1:00 p.m. LPA measured the water temperature in the shared bathroom to be 106.2 degrees Fahrenheit.

At 1:15 p.m. LPA conducted a records review of resident and personnel files. All files were complete and available for audit.

During today’s inspection, no immediate health or safety hazards were observed.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2024
LIC809 (FAS) - (06/04)
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