197610188-9-23-2024-31-AS-MAGN-D9DURW-20240923154924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610188
Report Date: 09/23/2024
Date Signed: 09/23/2024 03:50:54 PM

Document Has Been Signed on 09/23/2024 03:50 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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ADVANCED HOME CARE SENIOR LIVING 2 LLC		FACILITY NUMBER:	197610188
ADMINISTRATOR/ DIRECTOR:	SANTOS, CATHERINE		FACILITY TYPE:	740
ADDRESS:	10109 GLADBECK AVENUE		TELEPHONE:	(818) 448-6836
CITY:	NORTHRIDGE	STATE: CA	ZIP CODE:	91324
CAPACITY: 6		CENSUS: 4	DATE:	09/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	CATHERINE SANTOS		TIME VISIT/ INSPECTION COMPLETED:	02:10 PM

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Licensing Program Analyst (LPA) Mariana Agban conducted an Annual Required visit and inspection of the facility. LPA arrived granted access by Staff. LPA met with Administrator Catherine Santos shortly after and explained the reason for the visit. The facility is licensed for a total capacity of six (6) non ambulatory residents of which one may be bedridden. Facility has a hospice waiver for six (6)

At approximately 10:10 am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms and carbon monoxide detectors were tested and were function properly. The fire extinguisher is located in the kitchen. The charge date is August 12, 2024.

Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of two day perishable and seven day non-perishable food at the facility; properly stored. Knives and sharps were stored in a locked kitchen cabinet.

Bedrooms: There were five (5) bedrooms designated for residents' use. All five bedrooms, in use by residents, were properly furnished with appropriate beddings and linens with sufficient lighting.

Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 116.8 and 117.9 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathroom during the inspection.

Common Areas: These included the living room and dining area. The common areas were properly furnished. Furniture was observed to be in good condition and adequate seating for residents. The auditory alarms on all exit doors were on and functional at the time of the visit.

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SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ADVANCED HOME CARE SENIOR LIVING 2 LLC	FACILITY NUMBER: 197610188
	VISIT DATE: 09/23/2024

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. There is a covered patio with three (3) small patio tables with chairs for residents use. All were observed to be clean and furnished with adequate seating.

Garage/Office/ Laundry: the garage is used for storage, staff office, and laundry. All the toxins, cleaning solutions, and disinfectants are also stored in the garage in a locked cabinet observed to be inaccessible to residents. LPA observed laundry appliances to be in good repair. The garage door is locked at all times and only staff have access to the garage.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and in compliance with licensing forms.

Medications: Medication and Medication Records were reviewed for proper documentation.

Temperature: Facility maintains a comfortable temperature of 75 degrees Fahrenheit

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Mariana Agban
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2024

LIC809 (FAS) - (06/04)

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