197610128-12-31-2021-31-AS-ADUA-CA9286-20211231160950

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610128
Report Date: 12/31/2021
Date Signed: 12/31/2021 04:11:34 PM

Document Has Been Signed on 12/31/2021 04:11 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:	WILLOWVIEW HOME CORP		FACILITY NUMBER:	197610128
ADMINISTRATOR:	ANGUIANO, EMALYN		FACILITY TYPE:	740
ADDRESS:	27828 PARKVALE DRIVE		TELEPHONE:	(818) 667-5411
CITY:	SAUGUS	STATE: CA	ZIP CODE:	91350
CAPACITY: 6		CENSUS:	DATE:	12/31/2021
TYPE OF VISIT:	Annual/Random	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Admin		TIME COMPLETED:	04:10 PM

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Licensing Program Analyst (LPA) Abeye Duguma met with the Administrator, Emalyn Anguiano, for a One (1) Year Required - Infection Control visit for this facility. LPA explained the reason for the visit. A tour of the physical plant was conducted at 1:30pm and the following was noted:
There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated outdoor visitors' area located in backyard. The facility has sufficient stock of PPE in a storage room located in the storage closet near the front entrance. The facility has a total of five (05) bedrooms, of which one (01) is a staff room and a total of two (02) bathrooms for both residents and staff. The facility is fire cleared for six (06) ambulatory, of which three (03) may be non-ambulatory, one (01) may be bedridden and a hospice waiver for six (06). The facility is currently occupying five (05) non-ambulatory residents, of which one (01) is bedridden and three (03) are under hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. The garage is being used for laundry and storage. Laundry detergents, cleaning agents and other toxins are stored in the locked garage. Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.
(continued on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: WILLOWVIEW HOME CORP	FACILITY NUMBER: 197610128
	VISIT DATE: 12/31/2021

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Knives and sharps are observed to be locked in a cabinet inaccessible to residents. Living and dining room furniture were also checked. The living room is neat and clean along with the dining room. The facility maintains a comfortable temperature at 70°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located, observed to be full and last inspected on 10/07/2021. Staff rooms were observed to be locked and located near the living room area. No medications are observed in the staff room. The residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 118.7°F. Towels and washcloths are not shared. There was enough clean linen available in the hallway cabinet. LPA observed medication to be locked and inaccessible to residents, located in the hallway cabinet. There is a complete first aid kit located in a locked cabinet near the family room.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:	DATE: 12/31/2021

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/31/2021

LIC809 (FAS) - (06/04)

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