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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610211
Report Date: 03/20/2025
Date Signed: 03/20/2025 01:29:32 PM

Document Has Been Signed on 03/20/2025 01:29 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:KITTRIDGE RCFEFACILITY NUMBER:
197610211
ADMINISTRATOR/
DIRECTOR:		MARTIR, FRANCISFACILITY TYPE:
740
ADDRESS:20702 KITTRIDGE STTELEPHONE:
(818) 854-6745
CITY:WINNETKASTATE: CAZIP CODE:
91306
CAPACITY: 6CENSUS: 6DATE:
03/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
08:51 AM
MET WITH:James Olaila - CaregiverTIME VISIT/
INSPECTION COMPLETED:
01:40 PM
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On 3/20/25 at approximately 8:45am an unannounced annual visit was conducted by Licensing Program Analyst (LPA) Perchui Milena Khurshudyan. Upon arrival, LPA met with the Caregiver James Olalia, who granted access to the facility. LPA introduced herself by showing her badge and explained the reason for the visit. Shortly after the Administrator, Michael Custodio arrived and helped with staff/residents’ files and medications.

During today's visit, LPA conducted a physical plant walk through, at approximately 9:35am, to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22.

The following was observed:

The facility is a single-story home and is licensed for capacity of six (6) residents, of which six (6) may be Non-Ambulatory and of which fire clearance for one (1) Bedridden. Facility also has a hospice waiver for six (6) residents. There are four (4) bedrooms and all four are designated for residents’ use. All bedrooms observed to be appropriately furnished and have appropriate lighting. There are two (2) bathrooms in the facility of which two (2) are designated for residents’ use and one (1) for staff use. LPA observed bathrooms have soap, paper towels and hand washing signs. The hot water temperature measured at 10:00am to be 118°F. Extra towels and linens were readily available in the linen closet located in the hallway next to bedroom #2. There are grab bars for each toilet and shower, bathrooms have non-skid mats. All trash cans in bathrooms had fitted lids to protect from cross contamination.

LPA observed facility alarms were present on all exit doors and all of the signals were functional.

SMOKE DETECTORS/CARBON MONOXIDE. The smoke detectors and carbon monoxide are hard wired, inter-connected and were located throughout the facility. At 12:00pm they were tested and observed to be operational. The facility has one (1) fire extinguisher that was last purchased on 4/8/2024.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE: DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/20/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KITTRIDGE RCFE
FACILITY NUMBER: 197610211
VISIT DATE: 03/20/2025
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KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, dish washer and sink. The kitchen appliances and fixtures were functional. LPA observed the kitchen area, there was sufficient stock of one week non-perishable foods and two days of perishable foods. Frozen foods are properly wrapped and stored. Food storage and preparation areas are clean and inaccessible to pests. LPA observed that sharp objects were stored inside staff room which was observed to be locked and inaccessible to residents in care. Extra emergency food was properly stored inside the kitchen cabinets. The common areas which include dining and living room appeared clean and were properly furnished. Temperature was comfortable it was measured at 10:35am to be 68°F. No obstructions and or tripping hazards throughout the facility found.

MEDICATION: LPA observed centrally stored medication is locked inside the staff room next to the kitchen area. First Aid kit was locked inside the kitchen cabinet, inaccessible to residents in care and it was checked by the LPA to be complete with new manual attached to it. Facility has two (2) staff for AM shift and two (2) awake caregiver for PM shift.

COMMON AREAS: LPA observed living room and a dining room that appeared generally clean and were properly furnished. No obstructions and or tripping hazards throughout the facility. Facility has land line; LPA checked its operational.

LAUNDRY ROOM: Laundry machines are located by the kitchen area and observed to be operational. LPA observed chemicals and detergents were stored and locked inside the staff room. LPA discussed the importance of keeping potentially dangerous items locked at all times.

SURROUNDING GROUNDS: LPA observed sufficient yard space with fenced backyard. Appropriate outdoor furniture, with covered shaded area available for residents to rest and enjoy outside weather. LPA discussed the importance of maintaining the care and supervision to meet the needs of clients. Exit doors were unlocked and free of obstructions. The facility does not have a swimming pool or body of water. There is a garage in the property, which is currently being used for storage.

FILE REVIEW: Between 11:15am to 12:30pm, LPA reviewed records and files of six (6) residents and five (5) staff/caregivers. A review of staff and resident records appeared to be complete. Resident’s files contain signed admission agreements and a medical assessment, and all other required documentarians.

Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: KITTRIDGE RCFE
FACILITY NUMBER: 197610211
VISIT DATE: 03/20/2025
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A review of staff records indicates that all facility staff and who required caregiver background checks have received criminal record clearances. There are no residents with prohibited conditions residing at the facility.

Facility provides activities to the residents in care, they also have activity coordinator who arrives once a week.An emergency exit plan/sketch along with other posting requirements are posted on the wall by the entrance area.

Medications Review: At approximately 12:35pm. LPA reviewed Centrally Stored Medication Destruction Records for proper documentation. Facility also maintains Medical Administration Records (MAR). PRN medications have written orders from a physician. Potentially dangerous items are kept inaccessible to residents in care.

LPA collected LIC500, LIC9020, copy of Liability Insurance Certificate, and copy of Administrator Certificate.

No citation issued during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:

DATE: 03/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/20/2025
LIC809 (FAS) - (06/04)
Page: 3 of 3