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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610596
Report Date: 08/14/2024
Date Signed: 08/14/2024 04:43:16 PM

Document Has Been Signed on 08/14/2024 04:43 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:A MYSTICAL ROSE VILLAFACILITY NUMBER:
197610596
ADMINISTRATOR/
DIRECTOR:		JABON, NELSON NFACILITY TYPE:
740
ADDRESS:21239 GEORGETOWN DRIVETELEPHONE:
(818) 294-3410
CITY:SANTA CLARITASTATE: CAZIP CODE:
91350
CAPACITY: 6CENSUS: 0DATE:
08/14/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:28 PM
MET WITH:Nelson Jabon, administratorTIME VISIT/
INSPECTION COMPLETED:
04:52 PM
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Licensing Program Analyst (LPA), Abeye Duguma, conducted an announced Pre-licensing visit at around 1:30 PM and met with administrator, Nelson Jabon. LPA conducted an entrance interview with the Administrator.

With the assistance of the Administrator, LPA conducted a facility tour of both the inside and outside. The facility was inspected for Fire Safety, Personal Accommodations and Services, Medication Procedures and Food Service. This is a single-story property. Fire Clearance is approved for five (05) non-ambulatory and one (01) bedridden resident.

Facility has three (03) semi-private bedrooms and one (01) bathroom for residents and one (01) bedroom for staff with its own bathroom. Resident bathroom has properly installed grab bars and shower has non-skid mat. All residents’ bedrooms are adequately furnished. The linens are stored in the storage space located in the hallway. Towels and washcloths are not shared.

The common areas are appropriately furnished. The living room and dining room are neat and clean. The LPA observed entertainment equipment and games for activities. Fireplace has appropriate screen. There is sufficient outdoor space with seating and a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

LPA inspected the kitchen and observed the stove and refrigerator to be clean and working. Facility has sufficient quantity and variety of nonperishable food supply. Nonperishable foods are stored in the pantry. Sharps observed to be stored in a locked kitchen drawer. All garbage containers observed to have lids.


(CONT. on LIC 809-C)
SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/14/2024
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: A MYSTICAL ROSE VILLA
FACILITY NUMBER: 197610596
VISIT DATE: 08/14/2024
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Smoke and carbon monoxide detectors were checked and function properly. There is a fully charged fire extinguishers located in the kitchen area, and near the front entrance, last inspected 02/09/2024. Hot water temperature measured at 111.9ºF during the visit. First-aid kit is complete.

LPA observed a washer and dryer in the garage. All chemicals, additional personal hygiene items and other toxins are stored in the locked cabinet in the garage.

At the time of this visit the physical plant is meeting Title 22 requirements.

The Component III was completed with the LPA.

No health and safety hazard were noted during this visit.

Exit interview was conducted and a copy of report was issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 08/14/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/14/2024
LIC809 (FAS) - (06/04)
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