197609320-11-6-2023-29-AS-SURA-CXBQ5Y-20231106105241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609320
Report Date: 11/03/2023
Date Signed: 11/06/2023 10:52:48 AM

Document Has Been Signed on 11/06/2023 10:52 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:	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: 5	DATE:	11/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Zhanna Davtian		TIME COMPLETED:	02:55 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual linspection. LPA Urena arrived at the facility at 10:10 a.m. and was greeted by staff. The Administrator Zhanna Davtian arrived shortly thereafter. The purpose of the inspection was discussed with the administrator.

At 10:45 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.

KITCHEN: Knives are stored in a locked kitchen drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. The freezer and refrigerator are stocked with a variety of foods. Prepared foods were safely covered with lids. The hot water temperature measured at 112.1 degrees Fahrenheit.

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

BATHROOMS: There are two bathrooms. There is 1 bathroom in the hallway, and 1 bathroom in bedroom #3. The bathrooms were clean, the 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 111.1 degrees Fahrenheit during today’s visit.

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: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

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: BLUE HORIZON ELDERCARE	FACILITY NUMBER: 197609320
	VISIT DATE: 11/03/2023

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COMMON AREAS: 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 extinguisher was observed to be serviced within the last year. The facility maintained a comfortable temperature of 73 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers was fully charged and were last serviced 02/20223. The LPA observed required postings throughout the common space.

GARAGE/OUTDOOR SPACE: The garage is connected to the house. The door to the garage was locked at the time of the inspection. An adequate supply of emergency food and water supply for six residents and two staff was observed. 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 to residents. The backyard has a shaded outdoor area equipped with outdoor furniture in good repair for residents’ use. There were no bodies of water noted.

RECORDS: Records review began at 12:15 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 12:50 p.m.; medications are centrally stored and locked in a file cabinet in the garage/office area; 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 reviewed the following documents:

- LIC500 Personnel Report; LIC9020 Client Roster; Liability Insurance

No deficiencies were cited at this time. Exit interview was 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: 11/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/03/2023

LIC809 (FAS) - (06/04)

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