195850173-9-29-2021-29-AS-SWAR-C7BQSD-20210929122521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850173
Report Date: 09/29/2021
Date Signed: 09/29/2021 12:26:33 PM

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:	A'MORECARE HOME ASSISTED LIVING		FACILITY NUMBER:	195850173
ADMINISTRATOR:	ELKAYAM, EDVA		FACILITY TYPE:	740
ADDRESS:	25311 BERDON STREET		TELEPHONE:	(818) 635-3500
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	09/29/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Edva Elkayam, Administrator		TIME COMPLETED:	12:30 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	Licensing Program Analyst (LPA), Salia Walker conducted a pre-licensing visit to this property at 9:00 a.m. on September 29, 2021, and met with applicant representative Edva Elkayam. This application is for a change in ownership from A'MORECARE HOME ASSISTED LIVING (197609109) to A'MORECARE HOME ASSISTED LIVING (195850173). This facility currently has a census of 5. The applicant has obtained fire clearance for a total capacity of four (4) non-ambulatory residents, and two (2) bedridden residents for a total capacity of six (6) clients. Fire clearance indicates ‘All bedroom for clients, not the staffroom, are cleared for bedridden.’ The LPA inspected the facility for Fire Safety, Personal Accommodations and Services, and Food Service. At 9:53 a.m., all hard-wired smoke alarms and carbon monoxide detectors were tested and function properly. The LPA observed one fire extinguisher to be fully charged with a purchase date of 09/10/21. From 9:55 a.m. until 10:57 a.m., the LPA reviewed staff files under previous ownership. From 11:13 a.m. until 11:33 a.m., the LPA reviewed resident files under previous ownership. There are six (6) single occupancy bedrooms for resident use. Five (5) out of six (6) resident bedrooms have a private bathrooms. There is one (1) staff bedroom. There is live in staff in bedroom #7. Each bedroom is equipped with clean mattresses, pillows and bedding. There is sufficient supply of linens, including blankets, bath towels and wash cloths. Bedrooms have sufficient lighting. The facility has two (2) common bathrooms for resident use. All common and private bathrooms contain appropriate non-skid mats and grab bars. Bathrooms have sufficient paper products. Night-lights were present in the main hallway. Between 12:04 p.m. and 12:16 p.m., hot water temperatures measured between 114.3 and 118.1 degrees Fahrenheit in the common and private bathroom(s). Continue on LIC 809C..

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

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: A'MORECARE HOME ASSISTED LIVING	FACILITY NUMBER: 195850173
	VISIT DATE: 09/29/2021

NARRATIVE

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The LPA toured the kitchen area at 9:18 a.m. The facility has a sufficient (7) day supply of perishable and non-perishable food. Appliances and all equipment appear to be clean and in good repair. Kitchen knives are stored in a locked cabinet. The kitchen has a sufficient supply of plates, cups, cook ware and utensils. Hot water measured at 118.2 Fahrenheit at 12:02 p.m. The living areas and dining areas are clean and properly furnished. All window screens and coverings are in good repair. The facility has enough seating to accommodate all residents. A working telephone is present. There are activity supplies stored utility room.
Medications will be stored and locked in a cabinet located in the kitchen. First aid kit was observed to have bandages, thermometer, scissors, tweezers and a current first aid manual. Facility records will be stored and locked in file cabinet. Cleaning and disinfectants are stored and inaccessible away in utility room.
Laundry area is located in the facility’s utility room. Laundry detergents and personal hygiene items are stored in a locked cabinet located in the utility room. There is an adequate supply of emergency water, along with emergency nonperishable food items kept in the utility room. There will be no firearms/ammunition stored on the property.
The facility has required postings, including emergency exit plan, Licensing Complaint Poster, Resident Personal Rights, Theft and Loss Policy, and Resident Council Rights. Facility has one central entry point designated for universal screening. Alcohol-based hand sanitizer available upon entry. Signs are posted throughout the facility to promote handwashing, and cough/sneeze etiquette. Facility has an adequate 30-day supply of Personal Protection Equipment (PPE). The exterior passageways were clean and clear of any obstructions. There are no bodies of water on the premises at the time of the visit. At 9:27 a.m., the LPA observed the backyard, which has a covered outdoor area for resident use. There are two (2) self-latching gates on the side of the house designated for an emergency exit. Physical plant is consistent with the submitted facility sketch/floor plan.
During today’s visit, the LPA reviewed the facility’s program plan, personnel policies, abuse reporting procedures, in-service training protocol, and medication procedures. The facility’s Mitigation Plan Report was provided during the pre-licensing inspection.
Comp III conducted. 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 under the new facility license number, until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.
The physical plant of this facility location is in compliance with Title 22 regulations at this time.
Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia Walker	TELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:	DATE: 09/29/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/29/2021

LIC809 (FAS) - (06/04)

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