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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610317
Report Date: 11/16/2022
Date Signed: 11/16/2022 12:21:51 PM

Document Has Been Signed on 11/16/2022 12:21 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:CASA MARINA RESIDENTIAL CAREFACILITY NUMBER:
197610317
ADMINISTRATOR:ADAMS, EULRONDAFACILITY TYPE:
740
ADDRESS:17029 ROMAR STREETTELEPHONE:
(805) 368-4972
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 0DATE:
11/16/2022
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Eulronda Adams TIME COMPLETED:
12:30 PM
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On 11/16/22 Licensing Program Analyst (LPA) Joscelyn Martinez arrived at the facility to conduct a Pre-licensing investigation. Upon arrival LPA met with Licensee Eluronda Adams and Designee Olga Litton. The purpose of the visit was explained. This is an application is for Residential Care Facility for Elderly. Facility has requested a total capacity of six residents (6). Fire clearance was approved for six (6) bedridden residents. This is a single-story home with five (5) bedrooms and three (3) bathrooms. Bedroom number five (5) will be designated for staff use.

Common Area: LPA observed the living room and furniture to be clean and in good repair. LPA observed the dining area to be clean and in good repair. The facility maintains a comfortable temperature at 69 degrees F, which meet regulations. The air conditioner is operational. No firearms observed or will be maintained on the premises. Facility contains dual smoke alarm and carbon monoxide detector. Detectors were operational and tested at 11:00 a.m. All of the resident’s doors are fire doors. Fire sprinklers are located throughout the house. The fire extinguisher was observed to be full with a service date of 09/02/22. Facility maintains a telephone landline that was tested and observed to be operational. Activities were observed in the living room closet area. Medications and files will be kept in a room located in the hallway. Closet is locked and inaccessible to residents. First aid kit was observed and contained the proper items stated by regulations.

Kitchen Area: LPA observed the kitchen area to be in good repair and sanitary. LPA observed a seven-day supply of nonperishable and a two-day supply of perishable food. Sharps were observed to be locked and inaccessible to residents. Trash can contain a tight-fitting lid. LPA observed plates and cups for resident’s use.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE: DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/16/2022
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: CASA MARINA RESIDENTIAL CARE
FACILITY NUMBER: 197610317
VISIT DATE: 11/16/2022
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Bedrooms: Facility has five (5) bedrooms in which one will be designated for staff. All bedrooms were toured and were observed with the appropriate furniture and bedding. Bedroom number one (1) and two (2) will be shared. Bedroom number three and four will be for private use.

Bathrooms: Facility has three (3) bathrooms of which two will be designated for resident’s use. Bathrooms were toured and were observed to have trash cans with tight fitting lids. The showers contained grab bars and non-skid mats. Hot water was tested and measured at 105 degrees F. LPA observed sufficient towels and wash cloths for residents.

Garage: Facility has garage that is accessible through the kitchen area. Garage will be used for storage and laundry area. Chemicals will be locked inside a cabinet.

Outside: LPA observed appropriate outdoor furniture with a shaded area for residents. Facility will be starting a garden in where residents can participate as an activity. There are no bodies of water. Facility has two sheds outside that will be utilized for storage.

Pre-Licensing Self-Certification checklist was discussed with administrator. LPA discussed preplacement staffing, training, customer service, inspection authority, reporting requirements (mandated reporter), records, citations, criminal record clearance, civil penalties, labor law, activities, expectation is to follow all rules and regulations. No deficiencies were observed.

Once component III is completed, this report will be sent to Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when the license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Joscelyn Martinez
LICENSING EVALUATOR SIGNATURE:

DATE: 11/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/16/2022
LIC809 (FAS) - (06/04)
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