195850216-1-27-2023-29-AS-SURA-CNGM33-20230127081426

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850216
Report Date: 01/26/2023
Date Signed: 01/27/2023 08:15:15 AM

Document Has Been Signed on 01/27/2023 08:15 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: 6	DATE:	01/26/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:08 PM
MET WITH:	Tina Arutyunyan		TIME COMPLETED:	04:39 PM

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Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. LPA Urena arrived at the facility at 2:05 p.m. This annual had a specific emphasis on infection control practices, and procedures. The purpose of the inspection was discussed with facility representative Tina Arutyunyan.

LPA Urena, and Ms. Arutyunyan 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. Kitchen, laundry, and house cleaning supplies are stored, locked, and located in the kitchen, and in the laundry room.

BEDROOMS: Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean, and in good condition.

Bathrooms: Bathrooms were clean, shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing signs were displayed, and sufficient amounts of soap and paper products in each restroom.

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: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

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: 01/26/2023

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Outdoor Space: Backyard is equipped with furniture in good repair for residents’ use. There were no bodies of water noted. Side gate is unlocked.

LPA Urena observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No citations were issued. Exit interview was conducted, the report was reviewed with the facility representative, and a copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/26/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/26/2023

LIC809 (FAS) - (06/04)

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