197609306-10-5-2023-29-AS-SURA-CWBK6Q-20231005073753

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609306
Report Date: 10/04/2023
Date Signed: 10/05/2023 07:38:31 AM

Document Has Been Signed on 10/05/2023 07:38 AM - 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:	ELAINE'S PLACE		FACILITY NUMBER:	197609306
ADMINISTRATOR:	BOTE, ELAINE P		FACILITY TYPE:	740
ADDRESS:	22745 DOLOROSA STREET		TELEPHONE:	(818) 340-7769
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 3	DATE:	10/04/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:16 AM
MET WITH:	Norma Gregorio		TIME COMPLETED:	02:45 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) Sandra Urena arrived unannounced at 10:15 a.m. to conduct a required annual visit. The LPA was greeted by staff. The LPA communicated with the Administrator Elaine Bote over the phone and explained the reason for the visit. The administrator stated that they were unable to come to the facility and stated that staff would be representing the facility during the inspection. At 10:45 a.m. the LPA, and the staff toured the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Knives and cleaning supplies are stored inaccessible in a cabinet under the sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 115. 5 degrees Fahrenheit. Medications were locked in a cabinet in the kitchen. BEDROOMS: Bedrooms had appropriate furniture, clean linens, and sufficient lighting. Rooms were clean and clear of obstructions. RESTROOMS: The restrooms were clean and sanitary with grab bars and non-skid surfaces. The facility has three (3) restrooms. Hot water temperature measured between 109.2 to 110.5 degrees Fahrenheit. The facility is stocked with soap and paper towels. Appropriate hand washing signs were observed. COMMON SPACES: The facility maintained a comfortable temperature of 75 degrees. Smoke and carbon monoxide detectors were operable. Furniture was observed to be in good condition. Two fire extinguishers were observed and located on a wall by the laundry room and another extinguisher was located in the kitchen area. Required posters were displayed throughout the common areas. Continues on LIC 809C...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

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

FACILITY NAME: ELAINE'S PLACE	FACILITY NUMBER: 197609306
	VISIT DATE: 10/04/2023

NARRATIVE

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OUTDOOR AREA: The backyard has patio furniture and a covered area. No obstructions observed in the passageways. No bodies of water were observed.

RECORDS: Records review began at 12:00 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 1:00 p.m. Medications are centrally stored and locked in a cabinet in the kitchen area, and in a locked box in the refrigerator for medications that require refrigeration. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors 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 requested the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/04/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/04/2023

LIC809 (FAS) - (06/04)

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