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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197607880
Report Date: 02/08/2022
Date Signed: 02/08/2022 12:53:32 PM

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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:FOUNTAINVIEW AT EISENBERG VILLAGEFACILITY NUMBER:
197607880
ADMINISTRATOR:ADAM PENAFACILITY TYPE:
741
ADDRESS:6440 WILBUR AVENUETELEPHONE:
(818) 741-5850
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY:216CENSUS: 102DATE:
02/08/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:02 AM
MET WITH:Adam PenaTIME COMPLETED:
12:53 PM
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At 10:02 AM on 02/08/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Administrator and disclosed the reason for the visit.

Census: 102

Garage: LPA started physical plant tour in the underground parking garage. The garage was locked from the outside and monitored by security. LPA observed an adequate supply of emergency water.

Elevators: All elevators had signs regarding masking requirements and social distancing practices. They also provided hand sanitizer stations, and emergency evacuation routes were clearly labeled.

Lobby: LPA observed the screening procedures for visitors, employees, and staff. All visitors provided vaccination records to staff at the front lobby. Facility maintained a log of visitor contact tracing information, temperature, and symptom screening. The main entrance also had signs regarding the masking requirement, coughing etiquette, social distancing, and symptoms of COVID-19. Employees recorded temperature and any symptoms in a log. Staff also recorded resident temperatures and screened for symptoms as they passed by. Administrator explained staff screen residents at least twice per day. LPA observed the most recent Provider Information Notice (PIN) available at the front desk.

Common Areas: Seating was arranged to accommodate social distancing. All furniture, flooring, walls, and ceilings were clean and in good repair. The facility provided a library and a computer with internet access, speakers, and a microphone. LPA also observed a handwashing station with fully stocked paper towels, liquid soap, handwashing instructions, and a trash can with a tight-fitting lid.

Administrator and LPA toured the Business Office, Dining Areas, Lounges, Creative Arts Room, and Event Center. Administrator notified LPA all rooms had been closed since December 2021 for community safety and COVID-19 policies.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
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 2
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: FOUNTAINVIEW AT EISENBERG VILLAGE
FACILITY NUMBER: 197607880
VISIT DATE: 02/08/2022
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Fitness Center: LPA saw a resident exercising with supervision and wearing a mask. Signs for the masking requirement were posted, and Administrator showed LPA the screening questionnaire required for entry.

Resident Room: At approximately 11:00 AM, Administrator and LPA toured two resident rooms on the first and fourth floor. Both rooms had fire sprinklers, functioning smoke detectors, laundry machines, telephones, and restrooms with grab bars around the toilets, showers, and tubs. All rooms were accessible with badges. At 11:20 AM, LPA checked the water temperature to be 113.3 degrees Fahrenheit.

Outdoor Space: LPA observed residents socializing in the courtyard area. LPA observed a shallow water fountain and a fireplace with a metal covering which was turned off. All access doors from the courtyard were locked, accessible by badges, and had masking requirement signs.

Hallways: Hallways were clean, in good condition, and monitored by cameras. LPA checked a fire extinguisher in the main lobby which was fully charged and last serviced in January 2022. LPA obtained documentation of a Fire Safety Inspection on 07/07/2021 from the Los Angeles Fire Department showing all systems passed.

At 10:29 AM Administrator and LPA reviewed the facility’s approved Mitigation Plan. Administrator showed LPA the isolation room setup for positive residents. The photograph showed signs hung on the isolation room door indicating Red Zone status, No Entry without PPE, Droplet Precautions, Contact Precautions, and Donning and Doffing instructions. Outside of the room was a cart with hand sanitizer and PPE.

Administrator also informed LPA resident rooms are cleaned on a weekly basis or as needed. All staff have been trained and residents have been informed of the facility’s infection control practices.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas ReedTELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:

DATE: 02/08/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2022
LIC809 (FAS) - (06/04)
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