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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610410
Report Date: 09/11/2023
Date Signed: 09/11/2023 01:32:41 PM

Document Has Been Signed on 09/11/2023 01:32 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:VAGTHOL'S RESIDENTIAL CARE CENTER #2FACILITY NUMBER:
197610410
ADMINISTRATOR:ROMERO, ELIZABETHFACILITY TYPE:
740
ADDRESS:751 S. MARIPOSA STREETTELEPHONE:
(323) 788-9924
CITY:BURBANKSTATE: CAZIP CODE:
91506
CAPACITY: 6CENSUS: 0DATE:
09/11/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:TIME COMPLETED:
01:40 PM
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At 9:30AM Licensing Program Analyst (LPA), Antonia Alvizar conducted an announced Pre-Licensing visit to the above facility and met with Administrator Elizabeth S Romero, Operations Director Joanne Olalia and Licensee Ann Seisa.
Fire Clearance was approved on 08/16/2023 for a maximum capacity of six (6) residents, of which six (6) non-Ambulatory and hospice waiver approved for six (6) residents. The purpose of today’s visit is to inspect the facility to ensure that the physical plant is in compliance with rules and regulations of California Code of Regulations, Title 22, Division 6, Chapter 8. The facility is a single-story building. During today’s visit at 9:55AM LPA inspected the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, two (2) sinks, and microwave oven. LPA observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. Fire Extinguishers were dated 05/23/23.

LAUNDRY ROOM: The laundry room is located outside the home divided with a lock door in the porch area. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use.

BEDROOMS: There are six (6) bedrooms designated for residents use and one (1) staff bedroom. All resident bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational.

BATHROOMS: At 10:30AM LPA inspected the bathrooms they are clean and in excellent condition. LPA observed two (2) bathrooms with grab bar and non-skid mats for residents to use and one (1) staff bathroom. Water temperature was within regulation. LPA also observed sufficient quantity of toilet papers, soap and paper towels.


Continue on LIC809-C
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE: DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/11/2023
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: VAGTHOL'S RESIDENTIAL CARE CENTER #2
FACILITY NUMBER: 197610410
VISIT DATE: 09/11/2023
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COMMON AREAS: The facility maintains a comfortable temperature at 70°F. The living room and dining area are clean and were properly furnished. In the living room LPA observed cabinet filed with books, magazines, board games and storage space.

MEDICATION: The medication will be kept in locked pantry closet in the kitchen area. The facility staff/resident files will be kept in a locked cabinet in the consultant area.

SMOKE DETECTORS/CARBON MONOXIDE.

Ten (10) smoke detectors and two (2) carbon monoxide detectors were located in the bedrooms and throughout the facility. At 11:30AM they were tested and observed to be operational.

SURROUNDING GROUNDS: The entrance to the home is gated. The back of the facility has sufficient yard space. LPA observed appropriate outdoor furniture, gardening flower beds with a covered shaded area for residents. LPA discussed the importance of maintaining the care and supervision to meet the needs of residents. There are no bodies of water.

Upon completing an inspection of the physical plant and reviewing a floor plan, LPA Alvizar noted that there was no garage in the facility. Based on LPA's review, no garage and driveway was required by Burbank Building & Safety and City Planning. The issue was discussed with the Administrator, and she indicated that car port garage and driveway is shared with property next door (753 S. Mariposa St.). Both properties are owned by the licensee Ann Seisa and they had all required approved permits. During this visit the Licensee representative was able to provide copies of the approved permits and original layout of 751 S Mariposa prior to purchase. LPA Alvizar informed the Administrator that the physical plant is meeting pre-licensing requirements.

Component III: Administrator, Elizabeth S. Romero completed the Component III during today’s Pre-Licensing visit



Based on inspection and observation, the physical plant is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and the applicant will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted and with a copy of this report was provided to Elizabeth S Romero.
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Antonia Alvizar
LICENSING EVALUATOR SIGNATURE:

DATE: 09/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/11/2023
LIC809 (FAS) - (06/04)
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