197608319-11-15-2024-29-AS-SURA-DB354B-20241115183717

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608319
Report Date: 11/15/2024
Date Signed: 11/15/2024 06:37:59 PM

Document Has Been Signed on 11/15/2024 06:37 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	CHRISTINE'S RETREAT		FACILITY NUMBER:	197608319
ADMINISTRATOR/ DIRECTOR:	CHRISTINE MKRTCHIAN		FACILITY TYPE:	735
ADDRESS:	17145 WILLARD ST		TELEPHONE:	(818) 578-8468
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 6		CENSUS: 6	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:07 AM
MET WITH:	Gevorg Mkrtchian		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection. The LPA was greeted by staff and informed them of the reason for the visit. Staff contacted the Administrator via phone and informed of the visit. The Administrator Gevorg Mkrtchian arrived thereafter.

The LPA and the Administrator 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.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 74 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. Fire extinguishers was fully charged and was last serviced 04/09/2024. The LPA observed required postings throughout the common space.

KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 112.8 degrees Fahrenheit.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated client rooms and one staff room. There was a linen closet in the hallway with extra towels and linens.

BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the hallway restroom at 112.8 degrees Fahrenheit.

Continues on LIC 809 C...

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHRISTINE'S RETREAT	FACILITY NUMBER: 197608319
	VISIT DATE: 11/15/2024

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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. The washer and dryer are located in room next to the kitchen. Cleaning supplies and disinfectants are kept in locked cabinets in the laundry room area.

RECORDS: Records review began at 12:06 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:35 p.m..; medications are centrally stored and locked in a cabinet adjacent to the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors were observed during the medication review.

INFECTION CONTROL: 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 a single isolation room if the facility has a confirmed case of COVID-19.

The LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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