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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610473
Report Date: 04/12/2024
Date Signed: 04/12/2024 03:05:20 PM

Document Has Been Signed on 04/12/2024 03:05 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 TRINIDADFACILITY NUMBER:
197610473
ADMINISTRATOR/
DIRECTOR:		AGUSTIN, GINAFACILITY TYPE:
740
ADDRESS:17326 LOS ALIMOS STREETTELEPHONE:
(818) 923-9687
CITY:GRANADA HILLSSTATE: CAZIP CODE:
91344
CAPACITY: 6CENSUS: 0DATE:
04/12/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:23 PM
MET WITH:Gina AgustinTIME VISIT/
INSPECTION COMPLETED:
03:15 PM
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Licensing Program Analysts (LPAs) Raymond Comer and Michael Cava conducted a Pre-Licensing Inspection with the applicant/administrator, Gina Agustin and her consultant, Jason Dy. An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on August 7, 2023. A fire clearance was approved on January 10, 2024 for two (2) ambulatoty, three (3) non-ambulatory residents and one (1) bedridden resident, for a total capacity of six. The applicant will be requesting a hospice waiver to retain six (6) residents. The smoke alarms and carbon monoxide detector are hard wired and inter-connected. The facility has two new fire extinguishers that was purchased in November 2023. One fire extinguisher is located in the living room, and the other in the garage.

A tour of the physical plant was initiated at approximately 12:23pm and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. There was an adequate supply of nonperishable food and dining ware to accommodate a maximum capacity of six (6). Perishable food not needed at this time as currently there are no residents. Knives will be locked in a kitchen drawer.

BEDROOMS: There are four (4) bedrooms. Three (3) are designated for client use. Bedroom #1 is private. Bedrooms #2 and #3 are shared rooms. One bedridden resident can be placed in either bedroom #1 or #2 (per STD 850). Bedroom #4 is reserved for staff. The applicant furnished the resident bedrooms with beds, night stand, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has three (3) bathrooms. Bedroom #1 and #3 has it's own bathroom with shower. The other bathroom is located at the hallway. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 120 degrees.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE: DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/12/2024
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 TRINIDAD
FACILITY NUMBER: 197610473
VISIT DATE: 04/12/2024
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COMMON AREAS: These included living room and dining room area. Furniture and floors were clean and in good repair. The dining area has a large dining room table to accommodate six (6). There were no visible immediate hazards.

LAUNDRY ROOM: The laundry room is located in the kitchen. It was observed with a locked door to make it inaccessible to the residents. The washer/dryer are brand new. Detergents and cleaning supplies are kept and maintained in the laundry room.

MEDICATIONS: Medications will be kept, locked and stored in the office/workstation.

OFFICE/STAFF WORKSTATION: Staff workstation is located by the living room. Resident and personnel files will be maintained in a locked filing cabinet there, alongside the medications.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home was clear of obstruction. All entry and exit doors have a functional auditory alert when the doors open. The backyard of the facility has a patio and backyard furniture to accommodate the six (6) residents. The facility backyard has sufficient yard space. There is no swimming pool or bodies of water.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held.

Pursuant to Title 22, Division 6 of the CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised and a copy of this report provided.

SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Michael Cava
LICENSING EVALUATOR SIGNATURE:

DATE: 04/12/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/12/2024
LIC809 (FAS) - (06/04)
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