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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610437
Report Date: 09/22/2023
Date Signed: 09/22/2023 03:41:10 PM

Document Has Been Signed on 09/22/2023 03:41 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:SYLMAR BOARD & CAREFACILITY NUMBER:
197610437
ADMINISTRATOR:OVAKIMYAN, ANIFACILITY TYPE:
740
ADDRESS:13100 FELLOWS AVETELEPHONE:
(818) 665-9631
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 0DATE:
09/22/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:22 PM
MET WITH:Andy Terner - Licensee representativeTIME COMPLETED:
03:45 PM
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Licensing Program Analysts (LPA) Gary Tan, Lorena Casillas and Gina Saucedo conducted an announced Pre Licensing visit to this facility and met with Licensee representative Andy Terner. The applicant is "Sylmar Board and Care". Fire Clearance dated 05/25/23 was received for six (6) non-ambulatory residents.

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.

Facility is a single storey home. Today's site visit consisted of LPA touring the physical plant at 12:35 PM inside and outside and observed the following:

The facility smoke alarm system is hard wired and interconnected. The fire extinguishers are located near the main entrance door and dining area and were observed to be fully charged and last bought on 07/08/2023. The facility uses a dual Carbon Monoxide/Smoke alarm detectors all over the common areas of the facility. Alarms were tested and observed to be operational. Hot water was tested in the common bathroom and measured at 112.3°F. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are four (4) resident bedrooms, room #1 and room #3 are shared room and the rest are private rooms. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen, office and dining areas) were appropriately furnished and lighting was adequate. The living room has a comfortable furniture. Residents, staff records and medications are stored in a designated secured cabinet in the dining area. The first aid kit is readily available. There are two (2) bathrooms in the facility. The bathrooms have appropriate grab bars installed and non-skid mats. One (1) bathroom is a designated staff/visitor use.

(continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/22/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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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: SYLMAR BOARD & CARE
FACILITY NUMBER: 197610437
VISIT DATE: 09/22/2023
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(continued from LIC 809)

The kitchen knives and sharps are stored in a locked drawer in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet below in the hallway. Laundry detergents, cleaning supplies and other toxins are stored in a locked cabinet in the laundry area. The laundry area is located at the backyard. The necessary precautions have been made to the facility to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Auditory alarms were tested and observed to be operational. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

There is a screening station immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing mask. Required poster are posted all over the facility. The facility had submitted a Mitigation and Infection plan.

There is a sitting area in the front yard for residents to conduct outdoor activities. The backyard is fenced. There is no body of water in the facility. There is a shed at the backyard being used as a storage for frozen food, PPE and other supplies. The garage was converted to and additional dwelling unit (ADU) and under construction and has a separate address. It has separate ingress and egress and no access from the inside of the facility.

Component III was waived as approved by LPM Troy Agard as the licensee has two (2) other existing facility.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted and copy of this report issued
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:

DATE: 09/22/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023
LIC809 (FAS) - (06/04)
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