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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610481
Report Date: 05/06/2024
Date Signed: 05/06/2024 11:30:25 AM

Document Has Been Signed on 05/06/2024 11:30 AM - 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ORCHID FACILITYFACILITY NUMBER:
197610481
ADMINISTRATOR/
DIRECTOR:		FAHIMI, IDAFACILITY TYPE:
740
ADDRESS:6217 CALVIN AVETELEPHONE:
(424) 224-6294
CITY:TARZANASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 6DATE:
05/06/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Ida Fahimi, AdministratorTIME VISIT/
INSPECTION COMPLETED:
12:00 PM
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At 9:30 AM, Licensing Program Analyst (LPA), Huma Rahimi conducted an announced Pre-Licensing visit to the above facility and met with Ida Fahimi, Administrator. LPA conducted an entrance interview with the Administrator. At the time of this visit LPA did observe six (6) residents present in the facility. Fire Clearance dated 01/08/2024 and received for five (5) non-ambulatory and one (1) bedridden resident. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22. The facility is a double story building and only downstairs will accommodate residents in care. Upstairs of the facility is for staff use only. LPA toured the physical plant inside and outside and observed the following:

KITCHEN: At 9:40 MA, LPA toured the kitchen. The kitchen area is equipped with a refrigerator, microwave oven, sink. Stove was observed in a good working condition. LPA observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in the kitchen in a cabinet.

LAUNDRY ROOM: The laundry room is next to the kitchen. LPA observed the washer and dryer are in good repair. The laundry room has a cabinet where the laundry detergents and other cleaning supplies are locked and inaccessible to residents in care.


BEDROOMS: At 9:45 AM, LPA observed six (6) private bedrooms for resident’s use only. The facility has two (2) bedrooms upstairs and it is designated for staff us only. LPA observed all bedrooms properly furnished with beds, dressers and required bedding, chest drawer, and linen. The bedrooms have sufficient closet space and have sufficient lighting. Facility will have a live-in staff at the facility. LPA did not observe any obstruction or hazard.

Continue on LIC 809C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ORCHID FACILITY
FACILITY NUMBER: 197610481
VISIT DATE: 05/06/2024
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BATHROOMS: At 9:55 AM, LPA observed two (2) full bathrooms and two (2) half bathrooms. Bedroom # one (1) has an attached half bathroom, and bedroom # four (4) also has an attached half bathroom. All bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPA observed to have an appropriate non-skid mat. At 9:56 AM, the water temperature was noted at 115.2°.

COMMON AREAS: LPA observed all common area to be clean in good repair. The facility maintains a comfortable temperature at 74°F. The living room and dining rooms were properly furnished. No obstructions and or tripping hazards throughout the facility. The living room has a screened fireplace. There is a dinning table which can accommodate six (6) residents.



MEDICATION: Facility has medication that require refrigeration and LPA observed in a locked box in the fridge separate from food. Medications that do not require refrigeration are centrally stored and locked in the hallway by bedroom # five (5) in a cabinet.


SURROUNDING GROUNDS: The facility has a backyard and has sufficient space. LPA observe appropriate outdoor furniture, and a covered shaded area for residents. Facility has extra storage area where extra supplies and PPE are stored. There was an additional storage where extra emergency food and other toxins are stored and locked. The facility has two (2) extra bedrooms that are used by Administrator and observed to be locked and inaccessible to residents in care. There is no swimming pool or any bodies of water at the facility. All emergency exit paths were free from obstructions.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors were located throughout the facility, and at 10:10 AM they were tested and observed to be operational. LPA tested the dual functioning smoke and carbon monoxide detector in the living room to be operational. When tested, four (4) out of four (4) detectors functioned simultaneously and two (2) out of two (2) fire doors closed. At 10:12 AM, LPA observed a fully charged fire extinguisher in the kitchen. It was purchased and inspected on 09/09/2023.

Continue on LIC 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ORCHID FACILITY
FACILITY NUMBER: 197610481
VISIT DATE: 05/06/2024
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Between 10:40 AM, to 11:10 am, LPA reviewed records of two (2) residents and two (2) staff. LPA observed all records are current and up to date.

LPA will inform CAB Analyst for license approval.

Component III was conducted with the Administrator.

Pursuant to Title 22, the facility is compliant to regulation, and ready for license. This report will be forwarded to the Centralized Application Bureau (CAB). The applicant will be notified by the CAB Analyst when their license is approved.



Exit interview conducted and copy of this report signed and delivered.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 05/06/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2024
LIC809 (FAS) - (06/04)
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