197608685-12-24-2021-31-AS-ADUA-C9ZTF8-20211224134106

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608685
Report Date: 12/24/2021
Date Signed: 12/24/2021 01:42:04 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ATRIA SANTA CLARITA		FACILITY NUMBER:	197608685
ADMINISTRATOR:	JOHNNY ORTIZ		FACILITY TYPE:	740
ADDRESS:	24431 LYONS AVE		TELEPHONE:	(661) 254-9933
CITY:	SANTA CLARITA	STATE: CA	ZIP CODE:	91321
CAPACITY:	160	CENSUS: 113	DATE:	12/24/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:26 AM
MET WITH:	Venca Avivi, Nurse		TIME COMPLETED:	01:33 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) Abeye Duguma met with Venca Avivi, Nurse for a One (1) Year Required - Infection Control visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at 10:00am and the following was noted: There is one entrance being utilized at the facility, there are required posters posted at the main door. Screening area is located immediately upon entrance. Sign in sheet, infrared thermometer, hand sanitizer, gloves and masks are available. LPA was screened upon entry. All staff were observed to be wearing masks upon entrance and during the visit. Signs to wear masks and other COVID 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and throughout the facility. The facility has a designated outdoor visitors' area located in the courtyard. The facility has sufficient stock of PPE in a storage room located in the nurse’s office and storage. The facility has a total of one hundred thirty-four (134) bedrooms of which thirty-nine (39) are in the memory care (MC) building. There are ninety-five (95) bedrooms in the main building, each with its own bathroom and of the thirty-nine (39) bedrooms in MC, thirty (30) are Jack and Jill (one bathroom for every two bedrooms) and ten (10) bedrooms have their own bathroom, eleven (11) public restrooms for both residents and staff and one (01) staff only restroom. The facility is fire cleared for one hundred sixty (160) non-ambulatory of which sixty-seven (67) may be bedridden and a hospice waiver for ten (10). The facility is currently occupying one hundred thirteen (113) residents of which seventy-nine (79) are non-ambulatory and six (06) are in hospice care. The facility has outdoor furniture, with a covered shaded area for residents. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins are stored in the laundry room and in a locked cleaning supplies room. Food Service/Kitchen area was sufficiently stocked with at least two (2) days perishable and seven (7) days (continued on LIC 809-C)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2021

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ATRIA SANTA CLARITA	FACILITY NUMBER: 197608685
	VISIT DATE: 12/24/2021

NARRATIVE

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non-perishable food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked in a drawer inaccessible to residents. Living/common and dining room furniture were also checked. The living/common room is neat and clean along with the dining room. The facility maintains a comfortable temperature between 73-76°F throughout. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguishers are located throughout the facility, observed to be full and last inspected on 11/15/2021. The clients' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are well lit. Residents have enough personal hygiene product provided by both themselves and the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 115.3°F. Towels and washcloths are not shared. There was enough clean linen available in the residents' rooms. LPA observed medication to be locked in a mobile cabinet and inaccessible to residents, located in the Med Tech room. There is also a complete first aid kit located in the nurse’s office.

Exit interview conducted. Copy of this report issued.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Abeye Duguma	TELEPHONE: (818) 669-6814
LICENSING EVALUATOR SIGNATURE:	DATE: 12/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/24/2021

LIC809 (FAS) - (06/04)

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