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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610529
Report Date: 03/08/2024
Date Signed: 03/08/2024 12:16:05 PM

Document Has Been Signed on 03/08/2024 12:16 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 & CARE IIFACILITY NUMBER:
197610529
ADMINISTRATOR:OVAKIMYAN,ANIFACILITY TYPE:
740
ADDRESS:13102 FELLOWS AVENUETELEPHONE:
(818) 665-9631
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 0DATE:
03/08/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:04 AM
MET WITH:Andy Terner - Licensee RepresentativeTIME COMPLETED:
12:05 PM
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Licensing Program Analysts (LPAs) Gary Tan, Ray Come and Leizl Dela Cerra conducted an announced Pre Licensing visit to this facility and met with Licensee representative Andy Terner. The applicant is "Sylmar Board and Care II". Fire Clearance dated 02/01/24 was received for six (6) non-ambulatory residents, one (1) of which maybe bedridden on Room #2

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 LPAs touring the physical plant at 9:22 AM inside and outside and observed the following:

The facility smoke alarm system is hard wired and interconnected. The fire extinguisher is located near the dining area and was observed to be fully charged and last bought on 02/18/24. 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 115.3°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 #3 and room #4 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 will be stored in a designated secured filing cabinet in the dining area. The first aid kit is readily available in the kitchen. There are two (2) bathrooms in the facility. The bathrooms have appropriate grab bars installed and non-skid mats.

(continued to LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE: DATE: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/08/2024
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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: SYLMAR BOARD & CARE II
FACILITY NUMBER: 197610529
VISIT DATE: 03/08/2024
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(continued from LIC 809)

The kitchen knives and sharps will be stored in a locked drawer in the kitchen. Kitchen cleaning supplies are stored in a locked cabinet below the sink. 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 will be a screening station immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks will be available. Required poster are posted all over the facility. The facility had submitted a Mitigation and Infection plan.

There is a sitting area in the back and side yards for residents to conduct outdoor activities. The backyard is fenced. There is no body of water in the facility. There is a storage area beside the laundry at the backyard for PPE and other supplies. There is no garage at the facility only car ports on the side and front.

Component III was waived as approved by LPM Nichelle Gillyard as the licensee has two (2) other existing facility in good standing.

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: 03/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2024
LIC809 (FAS) - (06/04)
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