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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850239
Report Date: 10/22/2024
Date Signed: 10/22/2024 04:54:01 PM

Document Has Been Signed on 10/22/2024 04:54 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SILVER LIGHT CAREFACILITY NUMBER:
195850239
ADMINISTRATOR/
DIRECTOR:		KHACHATRYAN, ELBAFACILITY TYPE:
740
ADDRESS:8201 VANTAGE AVENUETELEPHONE:
(747) 228-4111
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 5DATE:
10/22/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
01:47 PM
MET WITH:Elba KhachatryanTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Trevor Byrne arrived to the facility to conduct an unannounced Case Management- Deficiencies inspection.

During the physical plant tour LPA observed a food storage shelf located in the storage room in the backyard of the facility. LPA observed expired food items on the shelf. LPA observed five (5) jars of peanut butter, two (2) bottles of ketchup, four (4) boxes of pasta, and one (1) jar of tomato paste to be past their expiration dates. Facility staff removed the items and agreed to dispose of the at the time of the visit.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE: DATE: 10/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/22/2024
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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Document Has Been Signed on 10/22/2024 04:54 PM - It Cannot Be Edited


Created By: Trevor Byrne On 10/22/2024 at 04:26 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SILVER LIGHT CARE
FACILITY NUMBER: 195850239

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
11/05/2024
Section Cited
CCR
87555(b)(8)

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87555 General Food Service Requirements
(b) The following food service requirements shall apply:
(8) All food shall be of good quality...

This requirement is not met as evidenced by:
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Licensee will conduct an audit of all food supplies at the facility and will dispose of all expired items. Licensee will submit a photo of disposed items to CCLD no later than POC due date.
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Based on observation the licensee failed to comply with the section cited above as 5 jars of peanut butter, 2 bottles of ketchup, 4 boxes of pasta, and 1 jar of tomato paste were found to be past their expiration dates which poses a potential health risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kasandra Lopez
LICENSING EVALUATOR NAME:Trevor Byrne
LICENSING EVALUATOR SIGNATURE:
DATE: 10/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/22/2024


LIC809 (FAS) - (06/04)
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