197609320-10-8-2021-29-AS-SURA-C7LQJP-20211008121303

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609320
Report Date: 10/08/2021
Date Signed: 10/08/2021 12:13:59 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BLUE HORIZON ELDERCARE		FACILITY NUMBER:	197609320
ADMINISTRATOR:	DAVTIAN, ZHANNA		FACILITY TYPE:	740
ADDRESS:	11729 BLYTHE STREET		TELEPHONE:	(818) 640-4703
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	6	CENSUS: 6	DATE:	10/08/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Zhanna Davtian		TIME COMPLETED:	12:10 PM

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On 10/08/2021, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. LPA Urena arrived at the facility at 9:30 a.m., and was greeted by the administrator Zhanna Davtian. The purpose of the inspection was discussed with the administrator.

At 9:45 a.m., LPA Urena and administrator conducted a tour of the inside and outside the facility 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 back of the property.

Infection Control: Upon entry, the facility has a sign in book, and sanitizing gel. Infection Control signage was visible at entrance. Temperature was taken by caregiver, before allowing LPA Urena enter the premises. Temperature was recorded in sign in sheet.

Common Areas: At 10:00am, LPA Urena and administrator toured the common areas (living room and dining room). The 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: At 10:10am, LPA Urena observed the kitchen/dining area. 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 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE HORIZON ELDERCARE	FACILITY NUMBER: 197609320
	VISIT DATE: 10/08/2021

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Garage Area: 10:20am, LPA Urena observed an adequate supply of emergency food and water supply for six residents and two staff. Diapers, and Personal Protection Equipment (PPE) is adequate, and the facility is able to obtain additional supplies as needed. Medications were observed to be locked away in the office/garage area and were inaccessible from residents.

Bedrooms: At 10:30am, LPA Urena observed the residents’ bedrooms. Bedrooms were furnished appropriately with appropriate furnishings, bed linens, and sufficient lighting. The facility has three bedrooms, which have double occupancy.

Bathrooms: At 10:40am, LPA Urena observed the residents’ bathrooms. Bathrooms were 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. Hot water in residents’ bathrooms measured at 114 degrees Fahrenheit during today’s visit. There is 1 bathroom in the hallway and 1 bathroom in bedroom #3.

Outdoor Space: At 10:50 am, LPA Urena observed the 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.

Facility Records: At 11:00 am LPA Urena conducted a review of resident, staff, and medication records. All files were complete.

The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate

No deficiencies were cited at this time. Exit interview was conducted, the report was reviewed with the administrator and a copy of the report was provided via email. Signatures were obtained.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/08/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2021

LIC809 (FAS) - (06/04)

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