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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609935
Report Date: 12/07/2021
Date Signed: 12/07/2021 12:34:21 PM

Document Has Been Signed on 12/07/2021 12:34 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:LAKESIDE VIEW ELDERLY CAREFACILITY NUMBER:
197609935
ADMINISTRATOR:DUENAS, RALPHFACILITY TYPE:
740
ADDRESS:14003 LAKESIDE STTELEPHONE:
(818) 688-0738
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 5DATE:
12/07/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Emiliano SiapnoTIME COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. Upon entry, LPA was greeted by caregiver Johnson Berce, who allowed LPA to enter. There have not been any active or past COVID cases at the facility, and all staff and residents are vaccinated and scheduled for the booster shot December 14, 2021. The current census is (5). LPA’s temperature was immediately taken and documented; a list of COVID-19 questions was asked; and LPA signed in the visitor book. LPA observed staff and residents to have full mask covering; a hand sanitizing station; PPE supplies at the front door. COVID-19, CDC, Department of Public Health, and Licensing postings on the walls. LPA requested Administrator to more signs; including the bathroom.

The infection control inspection began with the Administrator Emiliano. The facility has (4) bedrooms; (3) are private, and (2) are shared. Beds were kept (6) feet apart. All bedrooms were properly furnished. The common areas were observed to be clean, including bathrooms, with soap and towels. LPA conducted a mitigation plan review with the Administrator, to obtain information on how the facility has implemented the plan. The Administrator reported to LPA, that all staff and residents will receive the booster shot on December 14, 2021. There is currently no surveillance testing, due to everyone being vaccinated and will obtain the booster. If anyone displays symptoms, a hospice agency will conduct COVID testing for the facility. All new employee hires and new resident admits, must be properly screened, and obtain vaccination prior to employment and new admit. Administrator continues to conduct training to staff in relation to COVID-19. Administrator reported the facility receives departmental emails; who forwards them to staff to read. There is currently a paid sick leave policy in place. Staff who are positive, will quarantine at a hotel; paid by the Administrator, along with there salary. There are designated rooms for potential positive COVID clients.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/07/2021
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 2
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: LAKESIDE VIEW ELDERLY CARE
FACILITY NUMBER: 197609935
VISIT DATE: 12/07/2021
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PPE, chemicals, cleaning supplies, emergency food and water, personal hygiene supplies, and paper products are stored in the garage area. LPA observed a sufficient supply of all items during the visit. LPA observed the facility has Licensing requirement for food. Currently, the facility has sufficient staff, and has back-up staff in place if needed. Visiting policy is conducted outside and inside; the Administrator prefers non-vaccinated to conduct visiting outside in the patio area. Majority of visitors have been vaccinated.

The facility has not had any positive COVID-19 reports for staff or clients at the facility, since the pandemic. The Administrator informed LPA that they continue to implement the best practices for their facility, which has kept them COVID-19 free. The facility is aware to report any changes with clients and staff to Licensing and there LPA, pertaining to positive COVID-19 cases.

Exit interview was conducted with Administrator.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 12/07/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/07/2021
LIC809 (FAS) - (06/04)
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