195850317-2-1-2024-29-AS-SURA-D22PMM-20240201102630

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850317
Report Date: 01/31/2024
Date Signed: 02/01/2024 10:27:07 AM

Document Has Been Signed on 02/01/2024 10:27 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	STARLIGHT FACILITY INC.		FACILITY NUMBER:	195850317
ADMINISTRATOR:	TADEVOSYAN, NELLI		FACILITY TYPE:	740
ADDRESS:	7647 TUJUNGA AVE.		TELEPHONE:	(818) 378-7069
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 4	DATE:	01/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:11 AM
MET WITH:	Nelli Tadevosyan		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff and the LPA informed them of the reason for the visit. Administrator Nelli Tadevosyan arrived shortly thereafter.

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.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 72 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. Required postings were observed at the entrance of the facility. There is a television in the living room area. The facility’s smoke/carbon monoxide alarm systems are hard wired. All rooms were tested, and smoke/carbon monoxide alarm systems were in operating condition.

KITCHEN: A seven-day supply of non-perishable food, and perishable food supply was available. The supply of dishes is adequate. The appliances in the kitchen were clean and all appeared functional. House cleaning supplies are stored in locked cabinet under the sink. There were no pesticides or toxins stored near food, or preparation area. Fire extinguisher was last purchased on 01/16/2024. Refrigerator and freezer were within the required temperatures. The first aid supplies were complete, including a thermometer. The first aid kit is located in a cabinet in the kitchen area medications will be stored in locked cabinet located in the kitchen.

Continues on LIC 809 C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: STARLIGHT FACILITY INC.	FACILITY NUMBER: 195850317
	VISIT DATE: 01/31/2024

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BEDROOMS: Facility has three (3) bedrooms for resident use. There is no bedroom available for staff use. Bedrooms are for double occupancy. Bedroom #3 is approved for one (1) bedridden resident. Lighting in the rooms appeared adequate. All bedrooms had adequate closet and drawer space for clothing and personal belongings. The supply of linens is sufficient to permit changing weekly or more often as needed to ensure change of linens at all times.
BATHROOMS: The facility has two bathrooms. Bathrooms are fully stocked with paper towels, and liquid hand soap. The showers have non-skid surface mats. Hot water temperatures were recorded in Fahrenheit degrees as follows:117.6 degrees for bathroom #1, and 118.2 degrees for bathroom in bedroom #3. Hand washing signs were visible and posted.
OUTDOOR AREA/GARAGE: The back patio is furnished with outdoor furniture for residents’ use, and shade is available. Fire emergency gates are clear of obstructions. The facility has a gated pool, and is inaccessible to residents. The garage is detached from the facility. The laundry area is located inside the garage..
RECORDS: Records review began at 1:30 p.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 were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 2:09 p.m.; medications are centrally stored and locked in a cabinet in the kitchen 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: 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 LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 01/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/31/2024

LIC809 (FAS) - (06/04)

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