197610188-9-9-2021-31-AS-TCAS-C6PP7J-20210909110401

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610188
Report Date: 09/09/2021
Date Signed: 09/09/2021 11:05:00 AM

Document Has Been Signed on 09/09/2021 11:05 AM - 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:	ADVANCED HOME CARE SENIOR LIVING 2 LLC		FACILITY NUMBER:	197610188
ADMINISTRATOR:	SANTOS, CATHERINE		FACILITY TYPE:	740
ADDRESS:	10109 GLADBECK AVENUE		TELEPHONE:	(818) 448-6836
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6		CENSUS: 5	DATE:	09/09/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Catherine Santos & Karen Silva		TIME COMPLETED:	11:15 AM

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Licensing Program Analyst (LPA) Tuesday Cabiness conducted a PRE-LICENSING visit to the above address 10109 Gladbeck Ave, Northridge, CA 91324. LPA met with Administrator Catherine Santos and Licensee Karen Silva. The inspection included, fire safety, personal accommodations, building and grounds, furniture/equipment, food service, and medication procedures. Fire Inspection was approved on June 17, 2021 which met fire department requirements for (4) rooms either ambulatory or non-ambulatory, and room # 5 is cleared only for (1) bedridden resident. Each room has smoke detectors, and two rooms have exit doors. Facility sketch, emergency disaster plan, complaint procedures, personal rights, emergency exit plan, and other required Licensing postings were observed. COVID signs, visitor book, and hand washing station observed at the front entrance. Temperature was taken by staff and recorded.

The physical plant was toured inside and out with Administrator Catherine. The facility is a one level home, with (5) bedrooms, and (2) bathrooms. There is no staff room. Food supply was inspected and observed, and storage areas, cabinets, pantries, cupboards counters, and refrigerator were clean and appropriate for food preparation. There is a freezer stored in the garage filled with frozen meat and other food items. Knives and medication were stored in cabinets located in the kitchen area. Appliances were clean and functional, and utensils, plates, and cups were in good repair. Cleaning supplies, poisons, toxins and chemicals were locked and stored in the garage area. There was enough supply of linens and towels. Hygiene products were also available and located in the garage. LPA observed at least (30) day supply of PPE.

The common areas included the dining, living, bathroom, bedrooms, and staff lounge. Doors and passageways were clear and unobstructed. Walls, ceilings, floors, window screens and all other rooms were clean, in good repair, and appropriately furnished.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

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: ADVANCED HOME CARE SENIOR LIVING 2 LLC	FACILITY NUMBER: 197610188
	VISIT DATE: 09/09/2021

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Resident rooms observed to have a mattress with pad, sheets, pillow, bedspread, dresser, closet space, and chair. Bathrooms were clean had functional fixtures, with soap and towels, grab bars and hand washing signs were posted. The water temperature measured at 118.0 degrees Fahrenheit. The back yard is completely fenced with a gate easily accessible and unlocked. There are no swimming pools or other bodies of water, no visible hazards around the surrounding grounds.

Smoke detectors and carbon monoxide were hardwired and operating correctly. Fire extinguisher is fully charged. Internet and telephone installation was completed. First aid kit inspected. Garage area was locked and secured. Staff and client files will be stored in the staff office, located in the garage area.

No deficiencies or citations during visit, facility is ready to be licensed.

Exit interview and COMP III conducted. Report issued to Administrator Catherine Santos.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:	DATE: 09/09/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2021

LIC809 (FAS) - (06/04)

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