197607445-6-17-2023-31-AS-AINZ-CSVPB5-20230617110947

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607445
Report Date: 06/17/2023
Date Signed: 06/17/2023 11:09:53 AM

Document Has Been Signed on 06/17/2023 11:09 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
Lookup Error,
, CA

FACILITY NAME:	BLUE EAGLE VILLAS		FACILITY NUMBER:	197607445
ADMINISTRATOR:	ABRAHAM VALDEZ		FACILITY TYPE:	735
ADDRESS:	1630 N. BRIGHTON STREET		TELEPHONE:	(818) 557-7239
CITY:	BURBANK	STATE: CA	ZIP CODE:	91506
CAPACITY: 6		CENSUS: 4	DATE:	06/17/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:29 AM
MET WITH:	Abraham Valdez-Administrator		TIME COMPLETED:	11:09 AM

NARRATIVE

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On 6/17/2023 Licensing Program Analyst (LPA) Alfonso Iniguez conducted an unannounced annual required visit using the CARE Inspection Tool. LPA met with Abraham Valdez/Administrator and the purpose of today’s visit was explained. The facility is licensed to operate for (6) developmentally disabled or Mentally Ill adults ages 18 through 59;(4) non-ambulatory and (2) ambulatory clients. Currently, the home has (4) ambulatory and (0) non-ambulatory client. The clients are from: Lanterman Regional Center. (1) clients have Restricted Health Care Conditions, and (0) are utilizing postural supports or protective devices.

The home consists of five (5) bedrooms (1 bedroom is a staff bedroom), two (2) bathrooms, dining room, kitchen, living room, recreation area with laundry area, staff room, attached garage, backyard, front yard patio area, and an office with a staff bed.

LPA Iniguez and administrator toured the inside and outside of the facility. (see D page for citations) All client rooms were checked. Mattresses and box springs were in good condition, adequate lighting was observed, plenty of dresser and closet space was observed. Bed linens, comforters and bath towels were adequately stocked at the time of visit. Bathrooms were found to be within Title 22 regulation. Toilets and water faucets worked properly. Shower was free of mold/mildew, there is adequate lighting, and sufficient toiletries accessible to clients. The water temperature properly measured between 105F°-120F° degrees (Kitchen 112.9F°, Bathroom #1 116.6°F., Bathroom #2 115.8F°).

Evaluation Report continues LIC 809-C

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023

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
Lookup Error,
, CA

FACILITY NAME: BLUE EAGLE VILLAS	FACILITY NUMBER: 197607445
	VISIT DATE: 06/17/2023

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Perishable and non-perishable food supply was checked and adequately stocked at time of visit. Carbon monoxide/Smoke detectors combo were observed and operational. Fire extinguishers were fully charged, toxins and knifes were locked and inaccessible to clients. Medications were centrally stored and properly locked, first aid kit was checked and fully stocked. Last facility fire drill was 5/14/2023.

LPA conducted a records review of (3) client records, (3) staff records and reviewed the facility disaster plan. The facility disaster plan was current and in compliance with Title 22 at the time of visit. LPA reviewed (3) Client Medication Administration Records (MAR) and did not observe any discrepancies at the time of visit.

Deficiencies cited under California Code of Regulations, Title 22, Division 6, Chapter 8.

See D pages for Citations.

Exit interview conducted and a copy of the appeal rights were given to Abraham Valdez/Administrator at the time of the visit.

SUPERVISORS NAME: Eva M Alvarez
LICENSING EVALUATOR NAME: Alfonso Iniguez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 06/17/2023 11:09 AM - It Cannot Be Edited

Created By: Alfonso Iniguez On 06/17/2023 at 10:56 AM

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
,
, CA

FACILITY NAME: BLUE EAGLE VILLAS	FACILITY NUMBER: 197607445
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 06/17/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

80087(a)(1)

Building and Grounds

(a) The facility shall be clean, safe, sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors. (1) The licensee shall take measures to keep the facility free of flies and other insects. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in keeping the facility free of insects which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Licensee will ensure facility will be free of insects. Lincensee will submitt proof of correction to LPA by POC due date via email.

Type B

Section Cited

CCR

80088(b)

Fixtures, Furniture, Equipment, and Supplies

(b) All window screens shall be in good repair and be free of insects, dirt and other debris. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in keeping the facility in good repair which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/07/2023
	Plan of Correction
1 2 3 4	Licensee will ensure facility will be in good repair at all times. Licensee will submitt proof of correction to LPA via email before POC due date.

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:

Eva M Alvarez

LICENSING EVALUATOR NAME:

Alfonso Iniguez

LICENSING EVALUATOR SIGNATURE:

DATE: 06/17/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/17/2023

LIC809 (FAS) - (06/04)

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