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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610354
Report Date: 02/27/2023
Date Signed: 02/27/2023 12:07:37 PM

Document Has Been Signed on 02/27/2023 12:07 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:PENDLETON HOUSEFACILITY NUMBER:
197610354
ADMINISTRATOR:KARIBIAN, MARY MAROFACILITY TYPE:
740
ADDRESS:12016 PENDLETON STREETTELEPHONE:
(818) 822-0911
CITY:SUN VALLEYSTATE: CAZIP CODE:
91352
CAPACITY: 6CENSUS: 0DATE:
02/27/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:20 AM
MET WITH:Mary KaribianTIME COMPLETED:
12:18 PM
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At 09:30 am Licensing Program Analyst (LPA) Tihesha Smith conducted an announced pre-licensing visit with License/ Identification of the Applicant/administrator was verified by CA photo ID.

The facility has a capacity of six (6). Application received for six (6) bed-ridden clients.

Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6.

Today's site visit consisted of LPA touring the physical plant inside and outside and observed the following:

The common areas (kitchen, living room, and dining areas) were appropriately furnished, and lighting was adequate. The facility has adequate non-perishable food supply. Appliances in the kitchen appeared to be functional. The living room/dining combination furnished with table and chairs. The sharps are stored and locked in lower kitchen cabinet. Toxins locked in bottom cabinet in bathroom #1. Laundry detergents, and other toxins are stored in locked detached garage.

Medications are stored in locked living room free standing cabinet. Resident and staff records also stored in locked cabinet. The first aid kit is readily available attached to living room wall.

There is a functioning telephone/landline on the premises. An emergency exit plan/sketch is posted near entrance/exit wall with other posting requirements.

There are five (5) rooms one (1) for staff with working call button on wall and four (4) client bedrooms, designated as

Room 1: Private Room 2: Private Room 3: Shared Room 4: Shared. Client bedrooms were observed to be appropriately furnished with a bed, nightstand, lamp, a chair, and free-standing closet. Extra linens stored in each client room. (Cont. to 809C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE: DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/27/2023
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: PENDLETON HOUSE
FACILITY NUMBER: 197610354
VISIT DATE: 02/27/2023
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(Cont. from 809)

There are two (2) bathrooms in the facility for clients use. The hot water was tested the bathrooms and measured 110.1 °F and 110.0°F. The bathrooms have non-skid mats, trash cans with lids and functional grab bars.

There is one (1) fire extinguisher located in the kitchen attached to wall. The fire extinguisher observed to be fully charged. Dual Smoke and Carbon Monoxide detectors were observed all over the facility, tested, and observed to be operational at approximately 11:35 am.

There is a front covered patio with table and chairs. There is a locked detached garage where laundry room is located and also used to store laundry detergents, excess water, and PPE/supplies. Garage observed to be locked and inaccessible to clients. There is no backyard and no body of water on the facility. Facility appears to be clean and in good repair.

Component III was conducted with the administrator and administrator confirmed understanding of Title 22.

At time of visit this facility is ready to be licensed.

This report will be forwarded to the Centralized Application Bureau (CAB).

Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Tihesha Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/27/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/27/2023
LIC809 (FAS) - (06/04)
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