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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801999
Report Date: 10/30/2024
Date Signed: 10/30/2024 03:43:50 PM

Document Has Been Signed on 10/30/2024 03:43 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:EDNA'S RESIDENTIAL CARE IIIFACILITY NUMBER:
565801999
ADMINISTRATOR/
DIRECTOR:		EDNA DANGIAPOFACILITY TYPE:
740
ADDRESS:1258 BEECHWOOD STREETTELEPHONE:
(805) 200-8156
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 6CENSUS: 5DATE:
10/30/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:20 AM
MET WITH:Edna DangiapoTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 10:20 A.M. LPA initially met with facility staff Magdalena Duya. Licensee/Administrator was contacted via telephone and arrived at the facility at 10:51 A.M. Entrance interview conducted.

Beginning at 10:52 A.M., the LPA, along with Licensee/Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. This facility doesn’t have a staff room, facility will provide 24/7 care. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.



The following was observed:

OUTDOOR SPACE: The backyard has a covered outdoor area equipped with furniture for resident use. All exits and passageways were observed to be free of hazards. There were no bodies of water noted. Facility has two total gates; both were observed to be self-latching and closing with clear passageways for emergency exit use.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives, staff and resident files and medication were observed to be locked inside kitchen cabinets at the time of the visit. At 11:23 A.M. hot water measured at 116.4 degrees Fahrenheit.

LAUNDRY ROOM/GARAGE: Adjacent to the kitchen is a separate laundry room and locked garage. Garage was observed and contained extra food, cleaning supplies and storage. Emergency food and water was observed. Cleaning supplies and hygiene products were observed to be locked in a cabinet and properly stored at the time of the visit.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE: DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/30/2024
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EDNA'S RESIDENTIAL CARE III
FACILITY NUMBER: 565801999
VISIT DATE: 10/30/2024
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Continued from LIC 809

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area. A fireplace was observed to be inaccessible to residents in care. The facility maintained a comfortable temperature of 71 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. Smoke detector was tested at 12:28 P.M. and carbon monoxide detector was tested at 11:01 A.M. and both were functional at the time of the visit. Fire extinguisher was observed to be fully charged and last serviced on 08/08/2024.

BEDROOMS: There are 5 (five) total bedrooms; 1 (one) of which is a shared resident room, 4 (four) are private resident rooms. The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: The LPA observed 3 (three) restrooms in the facility; 1 (one) is for shared use and 2 (two) are designated for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:58 A.M. and 11:17 A.M. hot water temperature was measured in all restroom and measured within the required range.

Continued on LIC 809-C

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EDNA'S RESIDENTIAL CARE III
FACILITY NUMBER: 565801999
VISIT DATE: 10/30/2024
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Continued on LIC 809-C

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. 5 (five) resident records reviewed were complete and contained all required documents. LPA observed that the Administrator has been using the Resident Appraisal (LIC603A) form in place of the required Appraisal/Needs and Service Plan (LIC625). Licensee stated that the LIC6003A has been utilized for several years and was unaware of the requirement for a LIC625 form. The LPA emailed the Administrator a copy of the LIC625 and explained that LIC 625 shall be completed annually or whenever there is a change in the resident’s condition. Technical advise issued. Four (4) staff files reviewed were complete and contained all required documents.

MEDICATION REVIEW: Medications for five (5) residents were observed. Medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review. Medications were observed to be maintained and administered in compliance with regulation.

INTERVIEWS: Throughout the visit, LPA interviewed 2 (two) staff and 2 (two) residents and a visitor.

During today's visit, LPA gathered the following items: Personnel Record (LIC500), Facility Roster (LIC9020A). A copy of the facility's liability insurance. Emergency disaster drills are conducted quarterly, with the last drill documented on 08/01/2024.


No deficiencies cited. Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Valeria Conway
LICENSING EVALUATOR SIGNATURE:

DATE: 10/30/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/30/2024
LIC809 (FAS) - (06/04)
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