195850068-9-14-2020-29-AS-BBAI-BTFPQU-20200914113144

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850068
Report Date: 09/14/2020
Date Signed: 09/14/2020 11:32:29 AM

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BELLAIRE SENIOR CARE LLC		FACILITY NUMBER:	195850068
ADMINISTRATOR:	BURSALYAN, KARPIS		FACILITY TYPE:	740
ADDRESS:	6523 BELLAIRE AVE		TELEPHONE:	(818) 688-1315
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91606
CAPACITY:	6	CENSUS: 0	DATE:	09/14/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:54 AM
MET WITH:	Karpis Bursalyan		TIME COMPLETED:	11:00 AM

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	A Pre licensing visit was initiated today by Licensing Program Analyst (LPA) Brian Balisi. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s pre licensing visit was conducted via Facetime at 10:00am with Licensee Karpis Bursalyan. This is a single-story residence. Fire Clearance is approved for six (6) residents. (5) non-ambulatory and (1) bedridden. Facility has three (3) bedrooms and two (2) bathrooms for resident use. The physical plant was toured inside and out with Licensee. LPA observed combo Carbon Monoxide / smoke detectors throughout the facility. LPA observed a fully charged fire extinguisher inside the kitchen. All rooms are set up with beds, night stands, comfortable/appropriate chairs, chest of drawers and closet space. Lighting in the rooms appeared adequate at the time of the visit. All rooms have overhead lighting. Room #1 would occupy a bed ridden client. LPA observed an exit way equipped with a ramp and handrails, it was observed to be free from obstruction at this time. Bathrooms are equipped with grab bars and non-skid materials. Hot water tested in the bathrooms measured at 106 degrees Fahrenheit The common areas were appropriately furnished, and lighting was adequate at the time of the visit. LPA observed kitchen knives and sharp objects stored in a locked drawer by the window. There is an adequate supply of perishable and non-perishable foods located in the fridge. LPA observed a sufficient supply of dried goods and other non-perishable items in cabinets near the fridge. The emergency food supply is kept at this location as well. The supply of dishes was adequate at this time. Continued on 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020

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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BELLAIRE SENIOR CARE LLC	FACILITY NUMBER: 195850068
	VISIT DATE: 09/14/2020

NARRATIVE

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Continued from 809

Medications and first aid kit will be stored in locked black cabinet along side the rear wall of the kitchen. Resident and staff records to be stored in a locked file cabinet. LPA observed an adequate supply of bed and bath linens.

The exterior passageways were clean and clear of any obstructions. There is a shaded patio area at the back of the house and it was equipped with tables and chairs for resident use. LPA observed adequate space to conduct activities. The entire property is fenced and main gate was inaccessible from the outside.
LPA observed a locked storage unit on the left side of house, which stored extra supplies, tools, toilet paper and other medical care supplies. LPA observed an accessory dwelling unit in the rear of the home to be empty at this time.

Component III conducted in conjunction with visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. A telephonic exit interview was conducted with Licensee, and a hard copy was provided via email for signature.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 09/14/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/14/2020

LIC809 (FAS) - (06/04)

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