197609320-11-21-2024-29-AS-TBYE-DB2TN2-20241115135200

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609320
Report Date: 11/15/2024
Date Signed: 11/21/2024 08:44:58 AM

Document Has Been Signed on 11/21/2024 08:44 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/ DIRECTOR:	DAVTIAN, ZHANNA		FACILITY TYPE:	740
ADDRESS:	11729 BLYTHE STREET		TELEPHONE:	(818) 640-4703
CITY:	NORTH HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 5	DATE:	11/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:01 AM
MET WITH:	Zhanna Davtian		TIME VISIT/ INSPECTION COMPLETED:	02:00 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) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 09:01 AM. LPA met with facility Administrator Zhanna Davtian. Entrance interview conducted and the reason for the visit was explained. Beginning at 09:03 AM the LPA, along with facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: GARAGE: LPA observed the garage to be inaccessible to clients in care. The garage was observed to contain two (2) secured cabinets, two (2) secured filing cabinets, the facility’s washer and dryer, extra care supplies, and adequate emergency food and water supplies. The two (2) secured cabinets were observed to contain extra cleaning supplies and laundry supplies. The two (2) secured filing cabinets were observed to contain facility files and resident medications. COMMON AREAS: This includes the living room, entryway, and dining room. LPA observed the dining room to be clean and properly furnished at the time of the visit. The dining room contains a dining table with adequate seating for resident use. LPA observed a fire extinguisher mounted in the entryway to be fully charged and purchased on 03/05/2024. LPA observed the entryway to contain all required postings. The living room was observed to be clean and in good repair. The living room contained adequate seating and activities for resident use. The facility’s combination fire and carbon monoxide alarms were tested at 10:11 AM and were functional at the time of the visit. Continued on LIC 809C.

Kasandra Lopez	TELEPHONE: (818) 596-4343
Trevor Byrne	TELEPHONE: 747-444-6104
	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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 ELDERCARE	FACILITY NUMBER: 197609320
	VISIT DATE: 11/15/2024

NARRATIVE

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KITCHEN: The LPA observed the kitchen area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives, utensils, and other sharp objects. LPA observed the facility refrigerator to maintain forty (40) degrees Fahrenheit and the freezer to maintain zero (0) degrees Fahrenheit.

BATHROOMS: There are two (2) bathrooms at the facility. One (1) bathroom is designated as a private resident bathroom, and one (1) bathroom is designated as a shared resident bathroom. Both resident bathrooms were observed to be clean and in good repair and were equipped with nonskid surfaces. Grab bars were observed in all resident showers and near all resident toilets, all were properly secured. The water temperature was measured between 113.5 and 116.6 degrees Fahrenheit, which is in compliance with regulation. LPA observed both resident bathrooms to contain appropriately secured cabinets containing personal grooming supplies for resident use.

BEDROOMS: There are three (3) bedrooms in the facility; all are designated as dual occupancy rooms. LPA and facility administrator toured all three (3) resident rooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Bedroom #2 contains a direct exit to the outside of the facility. Auditory alarms were observed on facility exits and all were functional at the time of the visit.

OUTDOOR SPACE: The facility is the back house on the property and has one (1) emergency exit gate located in the front of the lot; LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use.

RECORD REVIEW: Record review began at 09:40 AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, consent forms, and personal rights. Six (6) staff files were reviewed. All staff files contained the required documents and trainings. Five (5) resident files were reviewed all resident files contained all required documentation and signatures. No deficiencies were observed during record review.
Continued on LIC 809C.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

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: 11/15/2024

NARRATIVE

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MEDICATION REVIEW: Medication review began at 11:28 AM. Medications for five (5) of five (5) residents were observed. All medications were stored properly and were appropriately documented on their respective centrally stored medication and destruction record sheets. No deficiencies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility’s last emergency disaster drill was conducted on 10/03/2024. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan are reviewed/updated annually by the facility’s administrator.

INTERVIEWS: LPA interviewed one (1) resident and two (2) staff members. The resident interviewed stated that the staff are nice, treat them well, and are attentive to their needs. The resident had no concerns with the facility. LPA was unable to interview additional residents due to language barriers. Both staff interviews were conducted with the assistance of the facility Administrator acting as a translator. Both staff members interviewed understood their roles and responsibilities, the resident’s rights, the forms of abuse, and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

No deficiencies were observed during today’s inspection. Exit interview conducted and copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Trevor Byrne	TELEPHONE: 747-444-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 11/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/15/2024

LIC809 (FAS) - (06/04)

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