<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610230
Report Date: 01/21/2022
Date Signed: 01/21/2022 12:10:02 PM

Document Has Been Signed on 01/21/2022 12:10 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:JUST LIKE HOME B&C, INC.FACILITY NUMBER:
197610230
ADMINISTRATOR:ALVAREZ, ANDRIEFACILITY TYPE:
740
ADDRESS:27209 CABRERA AVENUETELEPHONE:
(818) 256-9138
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY: 6CENSUS: 6DATE:
01/21/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:52 AM
MET WITH:Andrie AlvarezTIME COMPLETED:
12:17 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) Abeye Duguma conducted an announced Pre-licensing visit at 10:00 AM and met with the Licensee Andrie Alvarez. This is a change of ownership application from SCV Senior Suites (LIC 197609629) to Just Like Home B&C, Inc (LIC 197610230). LPA conducted an entrance interview with the Licensee. At the time of this visit LPA Duguma observed three (03) individuals working in the facility. LPA Duguma also observed and assessed six (06) residents present in the facility. All residents appear to be clean and groomed.

With the assistance of the Licensee, LPA conducted a Facility Tour of both the inside and outside. The facility was inspected for Fire Safety, Personal Accommodations and Services, Medication Procedures and Food Service. This is a single-story property. Fire Clearance is approved for six (06) non-ambulatory and a hospice waiver for two (02). Facility has four (04) bedrooms of which one is for staff and the remaining three (03) are semi-private. The facility has two (02) bathrooms of which one (01) is used by staff and the other for residents. The residents’ bathroom has a properly installed grab bar and a non-skid mat in the shower. Hot water temperature measured at 119.8ºF during the visit. The facility maintains a comfortable temperature of 70ºF. All residents’ bedrooms were adequately furnished.

The common areas were appropriately furnished and had adequate furniture. The LPA observed entertainment equipment for residents. The resident and staff records were stored in a locked file cabinet located in the den. The first-aid kit is complete. The facility has adequate linen, water, perishable and nonperishable food supplies. The linens were stored in the hallway cabinet.

(continued on 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/21/2022
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 2
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: JUST LIKE HOME B&C, INC.
FACILITY NUMBER: 197610230
VISIT DATE: 01/21/2022
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
26
27
28
29
30
31
32
The facility has working alarms on all exits. Smoke detectors and Carbon Monoxide detectors were checked and function properly. There is one (01) fully charged fire extinguishers located in the kitchen and observed to be last purchased 01/06/2022.

LPA observed a washer and dryer in the garage. All chemicals, additional personal hygiene items were stored in the locked garage.

LPA inspected the kitchen and observed stove and refrigerator to be clean and working. Facility had sufficient quantity and variety of perishable and nonperishable food supply. Nonperishable food was stored in the pantry. The medications are stored in a locked cabinet located in the kitchen. Sharps are stored in a locked kitchen drawer.

There is enough outdoor space with seating and available shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

At the time of this visit the physical plant is meeting Title 22 requirements.

The Component III was completed with LPA Duguma on 01/21/2022.

No health and safety hazard were noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 01/21/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/21/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2