197610211-1-13-2023-31-AS-MCAA-CN2UCX-20230113142841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610211
Report Date: 01/13/2023
Date Signed: 01/13/2023 02:28:49 PM

Document Has Been Signed on 01/13/2023 02:28 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:	KITTRIDGE RCFE		FACILITY NUMBER:	197610211
ADMINISTRATOR:	MARTIR, FRANCIS		FACILITY TYPE:	740
ADDRESS:	20702 KITTRIDGE ST		TELEPHONE:	(818) 854-6745
CITY:	WINNETKA	STATE: CA	ZIP CODE:	91306
CAPACITY: 6		CENSUS: 6	DATE:	01/13/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:27 AM
MET WITH:	James Olalia		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, James Olalia and explained the reason for the visit. At 11:40am, with the assistance of staff, LPA took a tour of the physical plant. The facility is a one story building with six (6) bedrooms and two (2) bathrooms. Required postings were observed in the entry area. The smoke alarms are interconnected. The carbon monoxide detector is located in the hallway. It functions properly. There is a fully charged fire extinguisher located in the kitchen. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Bedrooms: There were six (6) bedrooms. Four (4) rooms are private and two (2) rooms are shared. There is also staff quarters, where centrally stored medications were observed to be locked and inaccessible to the residents. Resident bedrooms were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. One of the bathrooms is located in the shared room. Bathrooms were observed to be properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit. No cleaning supplies were observed under the bathroom sink. Common Areas: These included the living room and dining area. The common areas were properly furnished. Floors and furnisher were maintained and in good condition. The auditory alarms at all exit doors were functional at the time of the visit. Entry and exits were clear of obstruction.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

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: KITTRIDGE RCFE	FACILITY NUMBER: 197610211
	VISIT DATE: 01/13/2023

NARRATIVE

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Surrounding Grounds: The backyard had furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area is located near the kitchen.

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

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

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

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: Michael Cava
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2023

LIC809 (FAS) - (06/04)

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