197608280-5-16-2023-29-AS-AASO-CRW2SM-20230516173924

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608280
Report Date: 05/16/2023
Date Signed: 05/16/2023 05:39:45 PM

Document Has Been Signed on 05/16/2023 05:39 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	FOUR SEASONS ASSISTED LIVING CENTER LLC		FACILITY NUMBER:	197608280
ADMINISTRATOR:	CLARIZZE PUNIT		FACILITY TYPE:	740
ADDRESS:	12120 CHANDLER BLVD		TELEPHONE:	(818) 487-0770
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91607
CAPACITY:	49	CENSUS: 39	DATE:	05/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:10 AM
MET WITH:	Clarizze Punit		TIME COMPLETED:	05:50 PM

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Licensing Program Analyst (LPA) Angel Ascencio arrived at the facility unannounced to conduct a required Annual visit. The LPA met with Administrator Clarizze Punit and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with Administrator Assistant Ulka Sanghavi to ensure there are no health and safety hazards.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedrooms were observed to be single and double occupancy.

RESTROOMS: Resident restrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA observed sufficient amounts of soap and paper products. The LPA observed the appropriate poster in common restrooms. Restroom hot water were measured in resident restroom and common restroom between 105.0 and 120.0 degrees Fahrenheit between 10:40 a.m. and 02:18 p.m.

KITCHEN: At 12:50 p.m. the 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. The facility has a pre-set menu however offers the option for residents to choose from a variety of different options if menu choices are not to their taste.

COMMON and OUTDOOR AREAS: At 1:00 p.m. the LPA observed the outdoor area. A small patio area is adjacent to the building and is accessible to residents. A shaded area with furniture is accessible to visitors and residents to visit. The common areas included a front lobby area, downstairs entertainment area and upstairs activity room.

Continued on LIC 809 - C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

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

FACILITY NAME: FOUR SEASONS ASSISTED LIVING CENTER LLC	FACILITY NUMBER: 197608280
	VISIT DATE: 05/16/2023

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All areas were accessible for resident use with appropriate furnishings. The LPA observed cameras in all common spaces.All areas were clean, sanitary and in good repair. Smoke detectors are hardwired and interconnected. Fire alarm system and extinguishers were last serviced by the fire alarm company on 05/01/2023. The LPA observed required postings on the hallway walls and reminded the administrator to ensure that the Department Provider Notices are displayed appropriately. Flooring was checked for cleanliness and appeared in good condition.

Infection Control: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. 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 a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

Exit interview conducted and copy of the report were issued.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angel Ascencio	TELEPHONE: 747-230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 05/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/16/2023

LIC809 (FAS) - (06/04)

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