197608280-6-23-2021-29-AS-SURA-C4A29W-20210623171237

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608280
Report Date: 06/23/2021
Date Signed: 06/23/2021 05:13:34 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FOUR SEASONS ASSISTED LIVING CENTER LLC		FACILITY NUMBER:	197608280
ADMINISTRATOR:	MELISSA CHRISTOPHER		FACILITY TYPE:	740
ADDRESS:	12120 CHANDLER BLVD		TELEPHONE:	(818) 487-0770
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91607
CAPACITY:	49	CENSUS: 28	DATE:	06/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:30 PM
MET WITH:	Melissa Christopher		TIME COMPLETED:	05:15 PM

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At 1:30pm Licensing Program Analyst (LPA) Sandra Urena conducted Infection Control call, and asked infection control questions before arriving at the facility. At 1:45pm LPA was greeted by Administrator Melissa Christopher. LPA introduced herself and explained the reason for the visit. LPA conducted an unannounced required annual inspection visit.

Census: 28 Residents.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, and a sanitation station. A sign in sheet is available for sign in procedures. Infection Control signs were visible at entrance and throughout the facility.

Facility Tour: At 2:15pm, LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Bedrooms: At 2:30pm LPA observed the Resident’s bedrooms. Bedrooms were furnished appropriately with sufficient lighting. Some rooms have double occupancy and some have single occupancy.

Facility Records: At 2:45pm, LPA reviewed (three) staff and (three) residents’ records. All files are in good order.

Kitchen: At 3:15pm, LPA observed the kitchen/dining area. Knives are stored in a locked cabinet in the kitchen. 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. LPA was not able to speak with chef to discuss menu choices.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

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: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 06/23/2021

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Outdoor Space: At 3:30 LPA observed the Outdoor space. A small patio area is adjacent to the building and is accessible to residents. A shaded area is provided for visitors and residents to visit.

Interviews: At 4:00pm LPA interviewed three residents. All three residents stated that food is not the best, and one stated that food is dry and that no condiments are offered with meals. Administrator provided a set of four week cycle menus. Items on the menus appeared to be well balanced and varied. Breakfast is usually served between 7:00am to 7:30am and lunch between 12:00pm to 12:30pm.

The LPA 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 isolation rooms 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 at this time. Exit interview conducted. Signatures obtained. A copy of report was issued

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 06/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/23/2021

LIC809 (FAS) - (06/04)

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