195850216-2-10-2022-29-AS-SURA-CBHQPH-20220210112047

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850216
Report Date: 02/09/2022
Date Signed: 02/10/2022 11:20:51 AM

Document Has Been Signed on 02/10/2022 11:20 AM - 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, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELDERCARE HOMES, INC.		FACILITY NUMBER:	195850216
ADMINISTRATOR:	HEKIMYAN, LUIZA		FACILITY TYPE:	740
ADDRESS:	7754 COLDWATER CANYON AVENUE		TELEPHONE:	(818) 764-8545
CITY:	N. HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	02/09/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:16 PM
MET WITH:	Luiza Hekimyan		TIME COMPLETED:	02:30 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	Today's pre-licensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived at the facility at 9:00 a.m., and met with applicant Luiza Hekimyan. This is an application for a Change of Ownership (CHOW). The LPA, and the applicant 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. KITCHEN: Kitchen knives are stored locked and inaccessible in a kitchen drawer. A seven day supply of non- perishable foods was available. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food. Kitchen, laundry, and house cleaning supplies are stored, locked, and located in the kitchen, and in the laundry room. Hot water temperature was recorded at 105 degrees Fahrenheit. BEDROOMS: There are six bedrooms for resident use, and one bedroom for staff use. Lighting in the rooms appeared adequate. All bedrooms had adequate closet and drawer space for clothing and personal belongings. BATHROOMS: The bathrooms are fully stocked with paper towels, hand soap, and hand washing signs. The showers have non-skid mats. Hot water temperature was recorded at 105 degrees Fahrenheit. Continues on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

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

FACILITY NAME: ELDERCARE HOMES, INC.	FACILITY NUMBER: 195850216
	VISIT DATE: 02/09/2022

NARRATIVE

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COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other activity supplies in the living room.

Resident and staff records are stored in the staff’s room. The first aid supplies were complete, including a thermometer and a current version of a first aid manual were stored in the staff’s room. Medications are stored in a locked top cabinet in the kitchen area.

The facility’s smoke/carbon monoxide alarm systems were found to be in operating condition. There are two fire extinguishers throughout the facility. One fire extinguisher was serviced on 3/2021 and one fire extinguisher, located by the kitchen area was purchased on 8/2021. The laundry area is located in an adjacent room by the kitchen area. The supply of extra bed and bath linens is adequate. There is a functioning land line telephone on the premises, one portable and one stationary. Infection control and other posters are posted throughout the facility and hallways.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the outdoor, backyard area of the facility, and is furnished with outdoor furniture for residents’ use. The building has a central entrance for residents and visitors. Fire emergency gates are clear of obstructions.

Applicant completed Component III orientation at this time.

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 for Change of Ownership.

Exit interview was conducted and reviewed with applicant, Luiza Hekimyan. A copy of the report was provided via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

LIC809 (FAS) - (06/04)

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