195850533-12-20-2024-29-AS-TBYE-DC5RLX-20241220120753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850533
Report Date: 12/20/2024
Date Signed: 12/20/2024 12:08:10 PM

Document Has Been Signed on 12/20/2024 12:08 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:	BLYTHE SENIOR ASSISTED LIVING		FACILITY NUMBER:	195850533
ADMINISTRATOR/ DIRECTOR:	MURADYAN, ARAM		FACILITY TYPE:	740
ADDRESS:	13030 BLYTHE ST		TELEPHONE:	(818) 818-8005
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6		CENSUS: 0	DATE:	12/20/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Aram Muradyan		TIME VISIT/ INSPECTION COMPLETED:	12:15 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Trevor Byrne conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, Aram Muradyan. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is one story. At 09:00 AM, a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents; and, one (1) bedridden resident. The facility has two (2) private resident bedrooms, Rooms # one (1) and three (3) and two (2) shared room(s), Room # two (2) and four (4). Rooms number three (3) and four (4) have direct exits to the outside. Bedroom # four (4) is designated as the bedridden approved room. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath or toilet. There are no staff rooms awake night staff are required. All rooms were free of odors. All window screens were clean and maintained in good repair. There is one (1) bathroom in the hallway that is designated as a shared resident bathroom. Bedroom # three (3) has a private bathroom attached. Bathroom # three (3) is designated as a staff bathroom. The resident bathrooms have a shower/bathtub with non-skid materials. All toilets and showers have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105F and 120F. Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

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: BLYTHE SENIOR ASSISTED LIVING	FACILITY NUMBER: 195850533
	VISIT DATE: 12/20/2024

NARRATIVE

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Resident and staff records are stored in a cabinet which is currently located in the dining room. Medications are centrally stored in a locked cabinet in the dining room. The first aid supplies were complete, including a thermometer and a current version of a first aid manual and are stored in a cabinet in the dining room.

Kitchen knives are stored in a locked drawer in the kitchen. Stove burners are rendered inaccessible to the residents by the installation of child proofing devices. The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at forty degrees Fahrenheit (40*F). The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored securely under the kitchen sink and in the laundry room which is inaccessible to residents in care. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to nonprivate bathrooms. Stairways, inclines, ramps and open porches and areas of potential hazard to residents with poor balance or eyesight were made inaccessible to residents unless equipped with sturdy hand railings and unless well-lighted. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. There is a fireplace in the living room. It is screened and there are no tools. Alarms on all but one (1) exterior doors (Bedroom #4) were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit.

The smoke detector and carbon monoxide detectors were tested at 11:20 AM and functioned properly during the time of visit. There is one (1) fire extinguisher throughout the house. It is fully charged and does not exceed the expiration date.
Continued on LIC 809C.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLYTHE SENIOR ASSISTED LIVING	FACILITY NUMBER: 195850533
	VISIT DATE: 12/20/2024

NARRATIVE

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Hot water was tested in each bathroom, which included the resident bathrooms and staff bathroom, in addition to the kitchen; and, the hot water ranged from 118.4 to 120 degrees Fahrenheit. The laundry area is located in a locked room attached to the facility. The supply of extra bed and bath linens is adequate. Personal hygiene items (shampoos, soaps) were adequate and are stored in the resident bathrooms. Extra incontinence supplies are stored in the hallway closet and the laundry room. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted in all resident rooms and throughout the facility. The emergency telephone numbers are posted at the front entrance to the facility along with all other required postings.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by a gate located on the east side of the facility. The gate to the driveway is moved manually. There is a gate for persons to enter the front yard that did not self-latch at the time of the inspection. Additionally, the gate leading to the backyard of the facility was observed to not self-latch at the time of the inspection. There is a locked storage shed in the back yard that belongs to the landlord and is not associated with the facility. The facility is attached to an unassociated property that is inaccessible from the facility. There are two (2) bodies of water on the premises at the present time. One (1) fountain water feature that contains about 3-4 inches of running water and one (1) appropriately fenced off pool that is inaccessible to residents in care. There is no garage attached to the facility.
The following items must be corrected prior to licensure. Submit proof of corrections, along with a copy of this report, to LPA Trevor Byrne so that your application may be completed.

87705 Care of Persons with Dementia
(h) Outdoor facility space used for resident recreation and leisure shall be completely enclosed by a fence with self-closing latches and gates, or walls, to protect the safety of residents.

87705 Care of Persons with Dementia
(j) The licensee shall have an auditory device or other staff alert feature to monitor exits, if exiting presents a hazard to any resident.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Trevor Byrne
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2024

LIC809 (FAS) - (06/04)

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