197609317-3-26-2024-29-AS-SURA-D3QVDE-20240326162035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609317
Report Date: 03/26/2024
Date Signed: 03/26/2024 04:21:20 PM

Document Has Been Signed on 03/26/2024 04:21 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:	BLUE HORIZON		FACILITY NUMBER:	197609317
ADMINISTRATOR:	DAVTIAN, ZHANNA		FACILITY TYPE:	740
ADDRESS:	11727 BLYTHE STREET		TELEPHONE:	(818) 640-4703
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 6	DATE:	03/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:05 PM
MET WITH:	Asmik Arzuyan		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. LPA Urena arrived at the facility at 1:00 p.m., met with the facility representative Asmik Arzuyan and explained the purpose of the visit.

LPA Urena and Administrator conducted a tour of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a one-story dwelling located in the front of the property.

Common Areas: The common areas (living room and dining room), walls and flooring were checked for cleanliness and were observed to be in good condition. Furniture was observed to be clean, appropriate, and in good condition. Fire extinguishers were observed to be serviced within the last year.

Kitchen: Knives are stored in a locked box which is stored in the kitchen cupboard. Kitchen appliances were in operable condition. The facility has enough supply of perishable and a seven-day supply of non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Prepared foods were safely covered with lids.

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: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

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: BLUE HORIZON	FACILITY NUMBER: 197609317
	VISIT DATE: 03/26/2024

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Garage Area: An adequate supply of emergency food and water supply for six residents and two staff were observed. Diapers, and Personal Protection Equipment (PPE) is adequate, and the facility is able to obtain additional supplies as needed.

Bedrooms: Bedrooms were furnished appropriately with appropriate furnishings, bed linens, and sufficient lighting. The facility has three bedrooms, which have double occupancy.

Bathrooms: The residents’ bathroom was observed to be clean; shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed, and sufficient amounts of soap and paper products in each restroom.

Outdoor Space: Backyard has a shaded outdoor area equipped with outdoor furniture in good repair for residents’ use. There were no bodies of water noted.

This is part-one of the annual inspection. Due to time constraints, a continuation annual inspection visit will be conducted in the near future.

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

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 03/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/26/2024

LIC809 (FAS) - (06/04)

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