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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609947
Report Date: 09/30/2024
Date Signed: 09/30/2024 03:15:07 PM

Document Has Been Signed on 09/30/2024 03:15 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PRIMROSE 3FACILITY NUMBER:
197609947
ADMINISTRATOR/
DIRECTOR:		NAIMUDDIN, MUBEENFACILITY TYPE:
740
ADDRESS:17537 BLYTHE STREETTELEPHONE:
(323) 872-2755
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 5DATE:
09/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Drew AlcazarTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
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On 09/30/24, at 11:45 am., Licensing Program Analysts (LPAs) Gina Saucedo and Angelica Segovia arrived at the facility to conduct an unannounced, annual visit. Upon arrival, LPA met with caregiver Chris de Guzman and disclosed the purpose of the visit. The designee administrator was called and arrived about twenty-five (25) minutes later.

LPA asked for the census, resident, and staff rosters.

The facility tour started 12:50 pm Temperature of facility wall thermostat is observed and set to 71 degrees Fahrenheit.

Medications-LPA observed medication stored in cabinet locked and secured in the kitchen area inaccessible to residents in the kitchen area.

Kitchen area was sufficiently stocked with seven (7) days of perishable and seven (7) days of non-perishable food. Sharps are stored and locked in one of the cabinets in the kitchen on the right side of the sink. Toxins are kept secured and locked in one of the cabinets under the kitchen sink inaccessible to residents. There is one (1) fire extinguisher located against the wall in the kitchen area fully charged and dated August 2025. There were two (2) complete first aid kits stored in overhead cabinet in the kitchen.


There is a backyard which has outdoor furniture and grassy area for outdoor activities. There is no pool.

LIC 809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PRIMROSE 3
FACILITY NUMBER: 197609947
VISIT DATE: 09/30/2024
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The garage is attached to the house and was observed to be locked and used to store toxins, washer, and dryer. There is also one (1) refrigerator in the garage with extra food.

Bedrooms: There is five (5) resident bedrooms. There are two (2) bedrooms that have their private bathroom and are single occupied. One (1) bedroom that is shared and the other bedroom that is single, occupied. All five (5) bedrooms are properly furnished with proper lightning. The bathrooms have proper toiletry and grab bars. There is one bathroom that is located by the entrance of the facility that is used by staff and residents. The bathroom temperature of the water are within regulations. It reads between 114.4-118 Fahrenheit.

Living and dining room furniture is accessible for five (5) residents. There is a television, telephone line and enough seating for five (5) residents. Furniture was observed to be in good condition and there is no fireplace. The smoke/carbon monoxide detectors are hardwired and interconnected and were tested. They were functional.

Administrative: There is an annual fee due which is due as of 11/2023 for $495.00. The Insurance plan is updated and expires on 07/2025, disaster plan, administrator certificate, Designation of facility responsibility, Admission Agreement, Personal Rights, Staff LIS and resident rights signs are against the wall at the entrance of the facility, Infection Control and Disaster Plan, Ombudsman.



An exit interview was conducted, two(2) citations were issued, appeals rights and a copy of this report was given to the designee administrator.
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2024
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Document Has Been Signed on 09/30/2024 03:15 PM - It Cannot Be Edited


Created By: Gina Saucedo On 09/30/2024 at 01:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PRIMROSE 3
FACILITY NUMBER: 197609947

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/30/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87506(b)(17)(A)
87506(b)(17)(A) Resident Records: (b) Each resident’s record shall contain at least the following information:
Documents and information required by the following:(A)Pre-Admission Appraisal;

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above in two out of five resdients which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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The Licensee/Administrator shall send a copy of the Pre-Placement Appraisal of two residents that were missing this information.
Type B
Section Cited
CCR
87458(b)(1)
87458(b)(1)
(b) The medical assessment shall include, but not be limited to: (1) A physical examination of the resident indicating the physician's primary diagnosis and secondary diagnosis, if any and results of an examination for communicable tuberculosis, other contagious/infectious diseases or other medical conditions which would preclude care of the person by the facility.
This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in two out of five residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/21/2024
Plan of Correction
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The licensee/Administrator will ensure that two residents have their tubercolosis on fiile and will send a copy to LPA Saucedo.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Troy Agard
LICENSING EVALUATOR NAME:Gina Saucedo
LICENSING EVALUATOR SIGNATURE:
DATE: 09/30/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/30/2024


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