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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850386
Report Date: 04/11/2024
Date Signed: 04/11/2024 02:09:55 PM

Document Has Been Signed on 04/11/2024 02:09 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:ELEVATION BEHAVIORAL HEALTHFACILITY NUMBER:
195850386
ADMINISTRATOR/
DIRECTOR:
TANDON, NESHAFACILITY TYPE:
772
ADDRESS:5182 GARRETT CT.TELEPHONE:
(858) 695-4069
CITY:CALABASASSTATE: CAZIP CODE:
91302
CAPACITY: 6CENSUS: 0DATE:
04/11/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:10 AM
MET WITH:Matthew Mueller, Ama Reyes, Roxy Esquivel, Senia AlfaroTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a Pre-Licensing Inspection with Applicant Representatives Matthew Mueller, Ama Reyes, Roxy Esquivel, and Senia Alfaro. An Application to operate a Social Rehabilitation Facility (SRF) was received by Community Care Licensing (CCL) on 06/27/2023. A Fire Clearance was approved for a maximum capacity of six (6) ambulatory residents on 09/20/2023.

The proposed physical plant is a two (2) story single family dwelling located in a residential neighborhood of Hidden Hills/Calabasas, CA. The physical plant also contains a detached garage and room above, which includes a restroom and kitchenette. A tour of the physical plant was conducted beginning at 10:28AM and the following observed:

COMMON AREAS: On the first floor, these include the great room, dining room, breakfast nook, and laundry room. On the second floor, there is a theater room and a yoga room. The common areas were furnished to accommodate a maximum capacity of 6 (six) clients. There are several fireplaces throughout the facility in both common areas and bedroom space, which were all observed to be adequately screened and Licensee Representative stated are disabled. Cleaning supplies are stored in the locked garage. There were no immediate hazards observed. Fire extinguishers were observed throughout the facility; all were observed to be fully charged and last serviced either 02/02/2024 or 07/12/2023. At 11:22AM, hardwired smoke detectors and separate carbon monoxide detector were tested and all were functional at the time of the visit. Fire sprinklers were tested during the fire inspection and all functioned properly at that time.

TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: There is a house staff office on the lower level, and the medication area/staff office located in the facility attached garage. There is also a group room, and sitting/group room on the second story. Medications are stored in a locked cabinet and locked refrigerator inside the ground floor locked garage. The first aid kit was observed to be complete.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 195850386
VISIT DATE: 04/11/2024
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KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient emergency food and water supply to accommodate a maximum capacity of 6 clients for (seven) 7 days. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 (six) clients. Licensee Representative indicated knives and other sharps will be stored in locked and inaccessible to clients in care. There were no visible immediate hazards observed.

BEDROOMS: There are 5 (five) bedrooms, of which 4 (four) are designated for private resident use and 1 (one) is a shared room. 1 (one) shared room and 1 (one) private room are located on the first floor, 3 (three) private rooms are located on the second story. All bedrooms were equipped and supplied with appropriate furniture, bedding and linens, as well as emergency lighting. There were no visible hazards or discrepancies observed.

BATHROOMS: There are 6 (six) total bathrooms, 3 (three) on the ground floor and 3 (three) on the second story. 5 (five) restrooms are designated for private resident use and 1 (one) is designated as a staff bathroom. All Bathrooms were supplied with appropriate paper and hygiene products. Water temperature was measured in client bathrooms and measured within the required range of 105 degrees F to 120 degrees F at the time of the visit.

SURROUNDING GROUNDS: The front yard includes a driveway, walkways and landscaped areas, as well as a gazebo next to the detached garage and a sport court and batting cage behind the detached garage. There is a courtyard, with access from the dining room and staff office areas which contained outdoor seating and a non-functional water fountain. The backyard includes both paved and landscaped areas, a patio, furniture appropriate for outdoor use, shaded area, as well as an in-ground pool. The pool is kept inaccessible to clients with the use of fencing and a locked gate. The applicant representatives indicated that all staff will obtain water safety certification and the pool will only be utilized with proper staff supervision.

DETACHED GARAGE/UPSTAIRS AREA: The facility does contain a separate detached garage, which was observed to be set up as a recreation room/gym for client use. The upstairs area was furnished as a group room. Additionally, upstairs there is a kitchenette designated for staff use, as well as a restroom and storage area. Current Fire Clearance indicates this "detached garage and room above are not habitable spaces. These spaces are to be used for storage and vehicle use only." During today's visit, Applicant Representative

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
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: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 195850386
VISIT DATE: 04/11/2024
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spoke with Fire Inspector to clarify use of this space and steps to follow to request additional clearance for this space.

COMPONENT II/COMPONENT III ORIENTATION: A Component II Orientation was completed telephonically with the Applicant Representative on 12/06/2023. A Component III Orientation was conducted with Applicant Representatives during today's visit.

The following needs to be completed/clarified prior to issuing the license:

  • A new facility sketch indicating shared resident room, and use of space in the detached garage/room above
  • Updated fire clearance to include permitting and sprinklers in the detached garage and room above or these areas reclassified as indicated in the 09/20/2023 fire clearance on the facility sketch

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 conducted. A copy of the report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 04/11/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024
LIC809 (FAS) - (06/04)
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