195850239-4-15-2022-29-AS-SURA-CDHMJ5-20220415093832

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850239
Report Date: 04/14/2022
Date Signed: 04/15/2022 09:38:37 AM

Document Has Been Signed on 04/15/2022 09:38 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:	SILVER LIGHT CARE		FACILITY NUMBER:	195850239
ADMINISTRATOR:	KHACHATRYAN, ELBA		FACILITY TYPE:	740
ADDRESS:	8201 VANTAGE AVENUE		TELEPHONE:	(747) 228-4111
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 0	DATE:	04/14/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Elba Khachatryan		TIME COMPLETED:	03:00 PM

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The pre-licensing visit was conducted by Licensing Program Analyst (LPA), Sandra Urena. The LPA arrived at the facility at 10:30 a.m., and met with applicant Elba Kachatryan. This is a new facility application for five non ambulatory residents and one bedridden resident.

At 11:00 a.m., 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 the pantry cabinet. A seven day supply of non-perishable food was available. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen, and house cleaning supplies are stored in locked cabinet under the sink. Hot water temperature was recorded at 111.9 degrees Fahrenheit. Trash cans have a tight-fitting lid. There were no pesticides or toxins stored near food, or preparation area.

BEDROOMS: There are three bedrooms for resident use, each room has double occupancy. Bedroom #3 is designated for the bedridden resident. 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 and hand soap. The shower has non-skid surface. Hot water temperature was recorded at 111. 2 degrees Fahrenheit.

COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment in the dining room area.

Residents and staff records will be stored in a filing cabinet in an area adjacent to the kitchen area. Medications will be stored in locked cabinets found in an area adjacent to the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

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: SILVER LIGHT CARE	FACILITY NUMBER: 195850239
	VISIT DATE: 04/14/2022

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The facility’s smoke/carbon monoxide alarm systems are hard wired. All rooms were tested, and all smoke/carbon monoxide alarm systems were in operating condition. A fire extinguisher properly charged is located mounted on the wall between the kitchen and dining room area. The laundry area is located in the garage, behind locked door. The supply of extra bed and bath linens is adequate. There is a functioning telephone on the premises. Infection control and other posters are posted throughout the facility and hallways .

The exterior passageways were clean and clear of any obstructions. The patio is furnished with outdoor furniture for residents’ use, and shade is available. The building has a central entrance for residents and visitors. Fire emergency gates are clear of obstructions. A fenced, and locked swimming pool is found in the back of the house.

Pre-Licensing is incomplete with deficiencies to be resolved . During the inspection, the LPA and applicant observed the following corrections needed, prior to being licensed:
1. Ramp access for all residents to use as passage to the backyard.
2. Emergency water needed.
3. Hand washing signs posted in bathrooms.
4. Add auditory alarm for bedroom # 3
5. Clear bottom threshold from doors leading from the hallway to kitchen and common area, to be positioned at the level where wheelchairs and walkers may pass through safely.

At 2:30 p.m., the applicant completed Component III orientation.

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 was conducted and reviewed with applicant Elba Kachatryan . 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: 04/14/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/14/2022

LIC809 (FAS) - (06/04)

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