<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610651
Report Date: 09/26/2024
Date Signed: 09/26/2024 12:39:21 PM

Document Has Been Signed on 09/26/2024 12:39 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:ST. PAUL RCFEFACILITY NUMBER:
197610651
ADMINISTRATOR/
DIRECTOR:		OBTINALLA, ARNIDAFACILITY TYPE:
740
ADDRESS:22235 WYANDOTTE STREETTELEPHONE:
(818) 448-2967
CITY:CANOGA PARKSTATE: CAZIP CODE:
91303
CAPACITY: 6CENSUS: 5DATE:
09/26/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:Arnida Obrinalla, Administrator TIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
At 09:30am, Licensing Program Analyst (LPA) Angela Panushkina conducted a Pre-Licensing Inspection with the facility Administrator, Arnida Obrinalla. This is a Change of Ownership Application from facility #197610243 to #197610651 to operate a Residential Care Facility for Elderly (RCFE). A Change in Ownership (CHOW) Application to operate a RCFE was received by Community Care Licensing (CCL) on November 23rd, 2024. A fire clearance was approved on April 16th, 2024, for six (6) Non-ambulatory residents for a total capacity of six (6).

A tour of the physical plant was initiated at approximately 09:40am and the following was observed:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, gas stove, microwave oven and sink. There were adequate supplies of two (2) days of perishable and seven (7) days of nonperishable food, dining ware to accommodate a maximum capacity of six (6) residents. Knives and other sharps were observed locked under the kitchen sink and under stove cabinet. The fire extinguisher was located by the laundry/kitchen area and was last serviced on 11/21/23.

MEDICATIONS: The medications are kept in a cabinet located by the kitchen entrance. At approximately 09:45am LPA observed each centrally stored prescription and PRN medication has been logged in the medications log with proper documentation from the clients’ doctor. All medications are properly labeled and checked for expiration dates. First Aid and the new manual is also locked in the cabinet. LPA observed the First-aid has all proper items and is current.

OFFICE: Office is located by the kitchen area and has an exit door with properly functioning auditory alarm. LPA also observed an extra refrigerator with extra food available. All staff and residents files are kept in a locked file cabinet. Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE: DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/26/2024
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: ST. PAUL RCFE
FACILITY NUMBER: 197610651
VISIT DATE: 09/26/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
LAUNDRY ROOM: The washer and dryer is located in a kitchen area by the office and LPA observed all chemicals are kept locked and inaccessible to residents in care.

BEDROOMS: The facility has six (6) bedrooms, of which five (5) bedrooms are designated for residents' use and one (1) bedroom for staff use. The applicant furnished all clients' bedrooms with beds, night stands, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space.

BATHROOMS: The facility has three (3) bathrooms and were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids. The hot water delivered in the bathrooms measured at 09:50am to be at 110.1 degrees.

COMMON AREAS: These included living room and a dining room. The living room was equipped with furniture, a television, tables and chairs. There is no fireplace in the facility. The dining area has a dining room table to accommodate six (6) residents, a sofa and a piano. There were no visible immediate hazards. The facility has comfortable temperature of 72 degrees. At 10:20am, hard wired and inter-connected smoke alarms and carbon monoxide detectors were tested and observed operational.

SURROUNDING GROUNDS: The driveway, passageways and entrance to the home were clear of obstruction. The backyard of the facility is properly fenced, has a patio and backyard furniture to accommodate six (6) residents. There is no body of water.



RESIDENT FILES: From 10:40am to 11:10am LPA conducted a file review of five (5) resident records to ensure compliance of licensing forms.

STAFF FILES: From 11:10am to 11:45am LPA conducted staff file review, files were complete with all documents and training certificates.

In addition to the Pre-Licensing inspection, a Component III power point presentation was also held. Pursuant to Title 22, CA Code of Regulations, the facility's physical environment appears to be compliant and ready for licensure. CAB will be advised.

Exit interview conducted and copy of this report signed and delivered to the Administrator.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Angela Panushkina
LICENSING EVALUATOR SIGNATURE:

DATE: 09/26/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2024
LIC809 (FAS) - (06/04)
Page: 2 of 2