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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610490
Report Date: 12/03/2024
Date Signed: 12/03/2024 01:48:08 PM

Document Has Been Signed on 12/03/2024 01:48 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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ARCHWOOD ASSISTED LIVINGFACILITY NUMBER:
197610490
ADMINISTRATOR/
DIRECTOR:
ALINA SOLLOWAYFACILITY TYPE:
740
ADDRESS:17981 ARCHWOOD STREETTELEPHONE:
(747) 788-0208
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 5DATE:
12/03/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Alina Solloway,AdministratorTIME VISIT/
INSPECTION COMPLETED:
01:20 PM
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At 9:30 AM Licensing Program Analyst (LPA), Huma Rahimi, conducted an unannounced annual inspection at the facility mentioned above. LPA met with the Administrator Alina Solloway and explained the reason for the visit. Physical tour was conducted with the Administrator and LPA observed the following:

Kitchen: At approximately, 9:55 AM LPA toured the kitchen area and observed enough supplies of staple non-perishable for minimum 1 week and perishable for 2 days at the facility. All knives and sharps observed to be locked in a kitchen drawer. LPA observed all cleaning supplies to be locked under the kitchen sink. The kitchen is equipped with a refrigerator, microwave oven and a sink. A fire extinguisher was hanging on the kitchen wall and last serviced on 10/10/2024.

Medications: At approximately, 10:00 AM LPA observed medications are centrally stored and locked in a cabinet in the living room.

Bedrooms: LPA observed total of three (3) bedrooms designated for clients use. The facility is fire cleared six (6) non-ambulatory residents. Bedroom #1 and #3 are shared. The bedrooms have sufficient lighting and closet space. All bedrooms are properly furnished, clean and have appropriate bedding and linens. Facility has awake staff.

Bathrooms: The facility has three (3) bathrooms. The bathrooms were observed to have the proper fixtures, grab bars, and non-skid mats. The hot water delivered in the bathrooms measured at 107.8 degrees.



Common Areas: The facility maintains a comfortable temperature at 71°F. The living room and dining area appeared clean and were properly furnished. The living room has a television, comfortable furniture. No obstructions and or tripping hazards throughout the facility.
Continue on LIC 809C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/03/2024
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: ARCHWOOD ASSISTED LIVING
FACILITY NUMBER: 197610490
VISIT DATE: 12/03/2024
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Garage/Laundry: The facility does not have any garage. The laundry is located in a closet in the hallway by bedroom number one (1). Laundry detergents, cleaning agents and other toxins are locked in a separate closet next to the laundry closet.

Outside areas: At approximately, 10:15 AM LPA toured the outside area of the facility. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. LPA observed a locked storage where additional cleaning supplies were kept.

Smoke detectors/carbon monoxide. The smoke alarms and carbon monoxide detector are dueal and hard wired, and at 10:35 AM they were tested and observed to be operational.

Between 11:00 A to 12:30 PM, LPA reviewed records of five (5) residents and three (3) staff. Residents and staff records appeared to be complete and updated.

Administrative: LPA collected Certificate of Liability Insurance, and LIC500.

No deficiency cited during today’s visit.

Exit interview conducted and copy of this report signed and delivered.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 12/03/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/03/2024
LIC809 (FAS) - (06/04)
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