195850239-5-24-2023-29-AS-SURA-CS5SR7-20230524140549

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850239
Report Date: 05/24/2023
Date Signed: 05/24/2023 02:06:44 PM

Document Has Been Signed on 05/24/2023 02:06 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
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: 3	DATE:	05/24/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:40 AM
MET WITH:	Elba Khachatryan		TIME COMPLETED:	02:25 PM

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Licensing Program Analyst (LPA), Sandra Urena arrived unannounced at the facility at 9:45 a.m. to conduct the annual inspection. The LPA was greeted by the staff, and the LPA explained the reason for the visit. The Administrator Elba Kachatryan arrived shortly thereafter.

At 10:15 a.m., the LPA, and the Administrator 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 kitchen 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 109.7 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. The first aid supplies were complete, including a thermometer and a current version of a first aid manual.

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: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

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: SILVER LIGHT CARE	FACILITY NUMBER: 195850239
	VISIT DATE: 05/24/2023

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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 and was serviced on 03/27/2023. 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 .
OUTDOORS: 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.

RECORDS: Residents’ records review began at 11:23 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records review began at 1:00 p.m. Records were reviewed for, but not limited to personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:30 p.m.; medications are centrally stored and locked in a cabinet in the common area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has 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 LPAs discussed the new PIN changes regarding infection control.

The LPAs obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Staff schedule
No deficiencies cited at this time. Exit interview conducted. 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: 05/24/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/24/2023

LIC809 (FAS) - (06/04)

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