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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610009
Report Date: 03/11/2022
Date Signed: 03/13/2022 01:42:21 PM

Document Has Been Signed on 03/13/2022 01:42 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:TEESDALE VILLA RCFEFACILITY NUMBER:
197610009
ADMINISTRATOR:GUEVARRA, CORAZON HALILIFACILITY TYPE:
740
ADDRESS:7663 TEESDALE AVENUETELEPHONE:
(818) 356-5152
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 3DATE:
03/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Jose Jr. GuevarraTIME COMPLETED:
12:00 PM
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On 03/11/2022, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility at 9:00 a.m., unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices and procedures. LPA Urena met with Administrator Jose Guevarra, and explained the reason for the visit.

Infection Control: Upon entry, the facility had a central entry point for symptom screening, temperature checks, and 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.

At 9:20 a.m., LPA Urena and Mr. Guevarra conducted a tour of the inside and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Areas: At 9:25 a.m., LPA Urena observed the walls and flooring to be clean and in good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Fire extinguishers were observed to be serviced within the last year.

Continues on LIC809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/11/2022
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: TEESDALE VILLA RCFE
FACILITY NUMBER: 197610009
VISIT DATE: 03/11/2022
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Kitchen: At 9:45 a.m., LPA Urena observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff. The laundry room is equipped with a functioning washer and dryer. Toxic materials are stored in a cabinet in the laundry room. The room was locked at the time of inspection.

Bedrooms: At 10:00 a.m., LPA Urena observed two residents’ bedrooms. Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition. Extra linens are stored in the laundry room.

Bathrooms: At 10:15 a.m., LPA Urena observed the residents’ bathroom. Bathroom was clean, shower area was in clean condition with grab bars, and a non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed, and sufficient amounts of soap and paper products was available.

Outdoor Space: At 10:30 a.m., LPA Urena observed the Outdoor space. Backyard has a covered outdoor area equipped with outdoor furniture for residents’ use. There were no bodies of water noted. Side gate is unlocked.



No deficiencies cited during this visit. Exit interview was conducted. The report was reviewed with Administrator Jose Gurevarra, signatures were obtained, and a copy of the report was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 03/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2022
LIC809 (FAS) - (06/04)
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