197610671-2-21-2025-31-AS-PKHN-DE4T3M-20250221132235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610671
Report Date: 02/21/2025
Date Signed: 02/21/2025 01:25:37 PM

Document Has Been Signed on 02/21/2025 01:25 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:	REESEJOY CARE HOME IV		FACILITY NUMBER:	197610671
ADMINISTRATOR/ DIRECTOR:	ABEGONIA, SHANDEE		FACILITY TYPE:	740
ADDRESS:	7639 FAUST AVENUE		TELEPHONE:	(818) 912-6289
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91304
CAPACITY: 6		CENSUS: 3	DATE:	02/21/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Roberto Ramirez - Licensee		TIME VISIT/ INSPECTION COMPLETED:	01:30 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	On 2/21/25 at 9:30am, Licensing Program Analyst (LPA) Perchui Milena Khurshudyan conducted a Pre-Licensing Inspection with the Licensee Ramirez Roberto. This is a Change of Ownership Application from facility #197610175 to #197610671 to operate an Residential Care Facility for Elderly (RCFE). A Change in Ownership (CHOW) Application to operate the RCFE was received by Community Care Licensing (CCL) on July 2nd, 2024. A fire clearance was approved on December 5th, 2024, for six (6) Non-Ambulatory residents. No approval for Bedridden resident. Facility has Hospice waiver granted for six (6) residents. The smoke alarms and carbon monoxide detectors are hard wired and inter-connected, they were tested and are operational. The facility has one (1) fire extinguisher that was purchased on 10/7/2024 and is located on the wall next to the kitchen island. A tour of the physical plant was initiated at approximately 10:30am 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 inside kitchen cabinet next to the sink and chemicals observed stored inside locked cabinet under the sink. Kitchen area is open plan facing the dining areas. COMMON AREAS: These include living room and a dining room. LPA observed the area was generally clean and organized. The living room was equipped with furniture, a television, tables and chairs. There is fireplace nicely fenced and blocked with a coffee table. The dining area has a dining table to accommodate six (6) residents. There were no visible immediate hazards. The facility has comfortable temperature which was measured at 10:50am to be 71 degrees F. Continue On LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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: REESEJOY CARE HOME IV	FACILITY NUMBER: 197610671
	VISIT DATE: 02/21/2025

NARRATIVE

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BEDROOMS: The facility has four (4) bedrooms, and all bedrooms are designated for residents' use. All residents' bedrooms observed to be nicely furnished with beds, night stands, lamps, chairs, dresser, bedding and linen. The bedrooms have sufficient lighting and closet space. Additional linen is available inside each bedroom’s closets and inside the linen cabinet located in the hallway. Bedrooms #1 and #3 are for private use and bedrooms #2 and #4 are for shared.

BATHROOMS: The facility has two (2) bathrooms, both designated for residents’ and staff use. All bathrooms were observed to have the proper fixtures, grab bars, non-skid mats, trash cans with closed lids, paper towels and washing hands signs. The hot water delivered in the bathrooms measured at 11:10am to be at 115 degrees. Bathroom #1 is located in the hallway next to bedroom #1 and bathroom #2 is inside bedroom #4.

GARAGE: The garage is currently being used as storage for facility equipment, supplies and water. Garage is attached to the facility and has access from the dining area. Facility has second refrigerator in the garage fully stocked with perishable and nonperishable foods. Sufficient amount of emergency food is also stored inside the pantry located in the garage.

LAUNDRY ROOM: The washer and dryer is located in a garage. Laundry chemicals are also kept in the laundry area which is always locked and under supervision.

Client Files: From 11am to 12pm LPA conducted a file review of all client records to ensure compliance of licensing forms. Clients’ files are complete and kept locked in the in the commercial cabinet located in the office area next to the dining room.
Staff Files: Staff files are also kept in a locked commercial cabinet located in the office. From 12:00pm to 12:30pm LPA conducted staff file review, files were complete with all documents and training certificates.
MEDICATIONS: Medications are kept locked in the locked kitchen cabinet. At approximately 12:00pm to 1:00pm 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.
Continue on LIC809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

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: REESEJOY CARE HOME IV	FACILITY NUMBER: 197610671
	VISIT DATE: 02/21/2025

NARRATIVE

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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 a pool in the backyard which was observed to be properly fenced and locked. There are two (2) exit gates on both sides of the property, LPA checked gates were unlocked and easy accessible.

LPA observed the facility is clean, safe, sanitary and odorless. All window screens were in good repair. Auditory signals were installed on exit doors and operational. All passageways were free of obstruction.

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.

An emergency exit plan/sketch along with other posting requirements were available in the hallway next to the entrance.

No deficiency cited on today’s visit.

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

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Perchui Khurshudyan
LICENSING EVALUATOR SIGNATURE:	DATE: 02/21/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/21/2025

LIC809 (FAS) - (06/04)

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