197608319-11-9-2023-29-AS-BBAI-CXEUJS-20231109143802

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608319
Report Date: 11/09/2023
Date Signed: 11/09/2023 02:38:59 PM

Document Has Been Signed on 11/09/2023 02:38 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:	CHRISTINE'S RETREAT		FACILITY NUMBER:	197608319
ADMINISTRATOR:	CHRISTINE MKRTCHIAN		FACILITY TYPE:	735
ADDRESS:	17145 WILLARD ST		TELEPHONE:	(818) 578-8468
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 6		CENSUS: 5	DATE:	11/09/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:50 AM
MET WITH:	Erlinda Patos		TIME COMPLETED:	02:50 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. Upon arrival, LPA met with Erlinda Patos - Direct Support Professional and explained the reason for the visit. House manager Marsha Williams arrived shortly after. This home is licensed to serve six (6) ambulatory clients at Level III which North Los Angeles County Regional Center is the vendor. Potentially dangerous items are kept inaccessible to clients with developmental disabilities and intellectual disabilities. There is staff to meet the needs of clients with developmental disabilities and intellectual disabilities. At Approx. 08:50am, LPA toured the facility with Williams. All clients were at day programs during the time of the visit. The kitchen appeared to be relatively clean at this time and the appliances and fixtures functional during the time of visit. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in the top drawer in the area right outside of the kitchen. LPA observed drawer to be locked at this time. Medication cabinet was located in this area as well. LPA observed cabinet to be locked and inaccessible to clients in care. Laundry area was located next to the kitchen. Cleaning products were observed to be inaccessible at this time. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed four (4) bedrooms that includes a staff room. Staff room was observed to be inaccessible to clients in care and empty at the of the visit. All rooms are double occupancy. Extra linen are kept in a cabinet in the hallway. LPA observed a sufficient supply of linen and personal hygiene supplies in the hallway closet nearest to bedroom #1.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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: CHRISTINE'S RETREAT	FACILITY NUMBER: 197608319
	VISIT DATE: 11/09/2023

NARRATIVE

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There are three (3) common bathrooms at the home. LPA observed all bathrooms were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom between 105 - 120 degrees Fahrenheit. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Dining room furniture appeared to be relatively clean and functional at this time. Client files were observed locked in cabinets in the area outside of the kitchen. LPA observed first aid kits properly supplied in this cabinet as well. Fire extinguisher were observed to be fully charged and last serviced in April of 2023. Last emergency drill - Earthquake conducted 9/18/2023.

There was a shaded area with sufficient room for activities. LPA observed sufficient furniture designated for outdoor use. There are no bodies of water on the premises. LPA observed a sufficient amount of space for activities. LPA did not observe any obstructions to emergency exits at this time. At 9:30am, LPA observed the gate that exits to the driveway was difficult to open due to a faulty latch. LPA observed that staff had a new latch available and will replace it by end of today. LPA observed an attached garage to the home only accessible from the exterior. LPA observed a sufficient supply of PPE along with other supplies for facility use. LPA observed it to be inaccessible from inside the home, to clients in care at this time.

Records review began at 10:00 am, five (5) client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order at this time. LPA identified clients who were over the age of 59. Williams stated they will submit an exception request for those clients by end of day Monday 11/13/2023.

Personnel records began at 11am, records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order at this time.

Medications review began at approximately 1pm. The medications are centrally stored in a locked cabinet near the kitchen area. Medications are properly documented on the centrally stored medications and destruction record.

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SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

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: CHRISTINE'S RETREAT	FACILITY NUMBER: 197608319
	VISIT DATE: 11/09/2023

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LPA conducted interviews with staff from 1:30pm - 2pm.

The LPA spoke with Erlinda Patos regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has 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 any bedroom as a single isolation room as well as the ability to contact Regional Center for temporary placement for any confirmed case of a communicable disease. COVID-19 testing will be conducted weekly if there are any covid-19 concerns. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted and report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 11/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/09/2023

LIC809 (FAS) - (06/04)

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