198603543-5-4-2022-28-AS-CWOG-CE4URW-20220504154926

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 198603543
Report Date: 05/04/2022
Date Signed: 05/04/2022 03:49:43 PM

Document Has Been Signed on 05/04/2022 03:49 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME:	GLENOAKS SENIOR GARDEN		FACILITY NUMBER:	198603543
ADMINISTRATOR:	TEKEIAN, DIANA		FACILITY TYPE:	740
ADDRESS:	834 E GLENOAKS BLVD		TELEPHONE:	(818) 726-4871
CITY:	GLENDALE	STATE: CA	ZIP CODE:	91207
CAPACITY: 5		CENSUS: 0	DATE:	05/04/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	02:00 PM
MET WITH:	Diana Tekeian		TIME COMPLETED:	04:00 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	Licensing Program Analysts (LPAs) Christine Wong, Benette Pena, Ashley Calderon, Valeria Maldonado conducted an announced visit to the facility for purpose of a pre-licensing evaluation. An application was submitted to CCLD on 12/17/21, for initial license for a Residential Care Facility for the Elderly, to serve 60 years and older. The requested capacity is for 5 ambulatory, of which 1 maybe bedridden and 1 maybe non-ambulatory in bedroom#3. Structure: Facility is a 3 bedrooms, 2 bathrooms, single story house with a detached two cars garage. The facility consists of sitting room, dining area, living room, kitchen. The home has a gas fire place in the living room with a metal screen cover, and is inaccessible to residents. There is a large back yard with shaded area with tables and chairs for residents to use. The residents bedrooms are spacious and will easily accommodate the residents furnishings. . The exit and passageways are free from obstructions. The front, back and side areas of free of hazards and debris. Bedrooms Residents: There shall be no more than two residents per bedroom. Bedrooms#3 is for non-ambulatory residents. Bedroom #1 and #3 have two beds, two chairs, two night stands, closet. Bedroom#2 has one bed, one chair, one night stand and closet. Bedrooms Staff: No bedroom designated for awake-staff.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLENOAKS SENIOR GARDEN	FACILITY NUMBER: 198603543
	VISIT DATE: 05/04/2022

NARRATIVE

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Bathrooms:
All bathrooms have a working toilet, wash basin and shower. There is one bathroom that will accommodate non-ambulatory residents in a wheel chair.

Linens & Hygiene Supplies:
Beds have the required linen/supplies which include, pillowcase, mattress pads, fitted sheet, blanket and bedspreads. Adequate supply of linen stored in linen closet next to the pantry. .

Emergency Phone Numbers, Exit Plan & Menu:
Posted & readily available for review on the wall near the dining are. Fire Extinguisher located between kitchen and living room mounted on wall. The facility has a landline and the telephone number is 818-726-4871.

Food Service:
Dishes, cups and flat ware are stored in the kitchen cabinet, inspected and in good repair. Knives, cutlery and other sharp kitchen utensils are locked in the lock box and stored in the kitchen cabinet. Food supply adequate stored in the kitchen and the pantry and consists of the following: minimum two days perishable and seven days non-perishable. Dishwasher in kitchen properly installed and functioning.

Smoke Detectors:
All the smoke detectors and carbon monoxide detectors are interconnected and located in each bedroom and common area.

Appliances:
Refrigerator, Stove burners, oven, microwave are working properly. Each refrigerator has a measured temperature of at least 45 degrees Fahrenheit for appropriate food storage. Freezer is at (0) zero degrees Fahrenheit.

Toxins:
Locked/stored in the garage

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

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
CCLD Regional Office, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754

FACILITY NAME: GLENOAKS SENIOR GARDEN	FACILITY NUMBER: 198603543
	VISIT DATE: 05/04/2022

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Water Temperature:
The hot water temperature in two bathrooms were measured between 106.4 and 109.9 degrees F.
Medications, First-Aid Kit & Book:
A first aid kit has been inspected which has at least the following: thermometer, tweezers, scissors, antiseptic, bandages, gauze and current first aid manual, which are stored in locked cabinet near the dining area, available for staff use but inaccessible to residents.

Clients & Staff Files:
All the staff and resident files are stored in a locked cabinet near the dining area

Reading Material, Games, Equipment & Materials:
The facility has board games, books, and other recreational materials for the resident's use, commensurate with the plan of operation.

Fire clearance:
Fire Clearance with bedroom#3 is approved for non-ambulatory and bedridden in use was approved on 03/17/22

For the washing machine, dryer and the blind/curtain are currently unavailable in the facility, they have already ordered and LPAs also obtained the copy of the receipt of the order. The applicant will take a picture and send to LPA via email once the appliances arrived.

Component III:
Conducted at the Pre-Licensing visit, information provided about how to operate the facility within substantial compliance.

An exit interview was conducted and a copy of this report has been furnished to the applicant. Accordingly, LPA will submit a copy of this facility evaluation report to the Central Applications Bureau (CAB) for review. If the applicant has questions regarding the status of the application, they have been instructed to communicate with the CAB Analyst assigned to their application.

SUPERVISORS NAME: Christine Yee
LICENSING EVALUATOR NAME: Christine Wong
LICENSING EVALUATOR SIGNATURE:	DATE: 05/04/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/04/2022

LIC809 (FAS) - (06/04)

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