197608116-2-10-2022-29-AS-SURA-CBHQKR-20220210111443

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608116
Report Date: 02/09/2022
Date Signed: 02/10/2022 11:15:14 AM

Document Has Been Signed on 02/10/2022 11:15 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELDERCARE VILLA		FACILITY NUMBER:	197608116
ADMINISTRATOR:	MIKHAIL MINKOV		FACILITY TYPE:	740
ADDRESS:	7754 COLDWATER CANYON AVENUE		TELEPHONE:	(818) 764-2526
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 5	DATE:	02/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Luiza Hekimyan		TIME COMPLETED:	12:30 PM

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On 02/09/2022, at 9:00 a.m., Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices, and procedures. LPA Urena was greeted by the staff Olha Nikolaenko, and Luiza Hekimyan. Staff Hekimyan contacted the administrator via telephone and requested the administrator respond to the facility. Administrator spoke with the LPA and stated that they were not feeling well, and approved for staff Hekimyan to sign off on today’s inspection report.

Infection Control: Upon entry, the facility has a sign in book and sanitizing gel. Infection Control supplies and sign in was available at entrance. Temperature was checked and recorded.

At 10:00 a.m., LPA Urena and staff Nikolaenko, and Hekimyan conducted a tour of the inside and outside the facility to ensure there are no health, and safety hazards and facility is in compliance with Title 22 Regulations.

Common Areas: At 10:05 a.m., LPA Urena observed the walls and flooring to be clean and in good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Fire extinguishers were observed to be serviced within the last year.

Continues on LIC809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELDERCARE VILLA	FACILITY NUMBER: 197608116
	VISIT DATE: 02/09/2022

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Kitchen: At 10:20 a.m., LPA Urena observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff.

Bedrooms: At 10:30 a.m., LPA Urena observed the residents’ bedrooms. Bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition.

Bathrooms: At 10:40 a.m., LPA Urena observed the residents’ restrooms. Restrooms were clean, shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Handwashing signs were displayed, and sufficient amounts of soap and paper products in each restroom.

Outdoor Space: At 11:00 a.m., LPA Urena observed the Outdoor space. Backyard has a covered outdoor area equipped with outdoor furniture for residents’ use. There were no bodies of water noted. Side gate is unlocked.

LPA Urena observed 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 facility’s policies and procedures as it pertains to infection control are adequate

No deficiencies were cited during this visit. Exit interview was conducted. The report was reviewed with staff Luiza Hekimyan, and a copy of the report was provided. Signatures were obtained.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/09/2022

LIC809 (FAS) - (06/04)

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