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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850519
Report Date: 07/08/2024
Date Signed: 07/08/2024 01:00:07 PM

Document Has Been Signed on 07/08/2024 01:00 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:EMERALD HOME CARE OF VENTURAFACILITY NUMBER:
565850519
ADMINISTRATOR/
DIRECTOR:		GAGARIN JOVILITOFACILITY TYPE:
740
ADDRESS:2551 WARBLER AVENUETELEPHONE:
(805) 612-4197
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 0DATE:
07/08/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:42 AM
MET WITH:Jovolito GagarinTIME VISIT/
INSPECTION COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Rankin conducted an announced Pre-Licensing inspection at the facility today and met with Licensee Representative/Applicant Jovilito Gagarin and Caregiver Merlita Peacock.

The facility obtained a fire clearance on 05/16/24 for a total of 6 (six) non-ambulatory residence. During today's visit, LPA completed Component III with the Applicant Representative.

The facility is a single-story home in the Ventura area, which consists of 6 (six) bedrooms and 2 (two) bathrooms. Five of the bedrooms are resident rooms, 1 (one) is a staff/office room approved on the fire clearance. Beginning at 10:58AM, the LPA, along with Applicant Representative, conducted a physical plant tour to ensure there are no health and safety hazards and the facility is in compliance with regulation. The following was observed:

KITCHEN/FOOD SERVICE AREA: The facility has a sufficient supply of non-perishable foods, emergency food and water. Knives and sharp items will be stored in a locked cabinet under the sink. Cleaning supplies and disinfectants will be stored underneath the locked kitchen sink and in the locked cabinet above the washer. The facility has a sufficient supply of plates, cups, and utensils.

RESIDENT BEDROOMS/BATHROOMS: The resident bedrooms were observed. All 5 (five) bedrooms are furnished for resident use. The resident bathrooms were observed to be clean and sanitary with grab bars and non-skid mats.
Report continued on LIC 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/08/2024
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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: EMERALD HOME CARE OF VENTURA
FACILITY NUMBER: 565850519
VISIT DATE: 07/08/2024
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Hot water was measured in the kitchen and measured within the required range. Bathrooms had sufficient supply of hand soap and paper towels for resident use.

COMMON AREAS: The sitting area/television room, and dining area are furnished appropriately. Paint, windows, window coverings, and floors are in good repair. The LPA observed the required postings in the entry way. Auditory devices on all exits were operational. Common areas were maintained at 72 degrees during the visit. Combination smoke alarms and carbon monoxide detectors were tested at 11:27AM and were operational at this time. Fire extinguisher was observed to be fully charged and Applicant stated they were recently purchased. LPA advised Applicant to maintain the receipt from purchase or proof of annual inspection. The facility has a laundry closet located off the hallway leading to the garage, which contains an operational washing machine and dryer. Medications will be locked and centrally stored in a cabinet in the kitchen/dining area. First aid supplies were reviewed and observed to be in compliance. Activity supplies were observed, including games, and a piano. Internet services will be available for all residence use.

OUTDOOR SPACE: The back yard area is enclosed. Per fire clearance only one side of the house has a gate which was observed to not currently have self-closing or self-latching abilities, a plan to update the hinges for this specialized gate was discussed and will be implemented. The backyard contains a shaded seating area and appropriate outdoor furnishings. There are no bodies of water on the premises. The backyard contains access to a locked garage. LPA observed the garage to contain extra cleaning supplies, storage, and paper goods. LPA observed cameras located in the front yard area, these are from the prior home owners and will be removed. If replaced the Licensee Representative indicated they will submit an amended Plan of Operation as well as address them in the facility Admission Agreement, as advised by the LPA.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 07/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/08/2024
LIC809 (FAS) - (06/04)
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