197609542-5-17-2022-29-AS-SURA-CEJ3GA-20220517181402

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609542
Report Date: 05/17/2022
Date Signed: 05/17/2022 06:15:12 PM

Document Has Been Signed on 05/17/2022 06:15 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BLYTHE STREET ELDERLY CARE		FACILITY NUMBER:	197609542
ADMINISTRATOR:	OHANYAN, NONA		FACILITY TYPE:	740
ADDRESS:	13367 BLYTHE STREET		TELEPHONE:	(323) 947-7005
CITY:	N HOLLYWOOD	STATE: CA	ZIP CODE:	91605
CAPACITY:	5	CENSUS: 4	DATE:	05/17/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Nona Ohanyan		TIME COMPLETED:	03:00 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) Sandra Urena arrived at the facility unannounced to conduct a required annual visit at 1:00 p.m. This annual inspection had an emphasis on infection control practices and procedures. The LPA spoke with facility Administrator Nona Ohanyan. The LPA explained the reason for the visit. The LPA and the facility administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards, and that the facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Sharp objects and medications were observed to be locked in a file cabinet. BEDROOMS: The residents’ bedrooms were furnished with appropriate furnishings and sufficient lighting. One hospital bed is to set to be set up in bedroom #1 for one resident. The bed will be installed per the administrator by the end of the day. Administrator will send picture of bed set up in bedroom #1 by Friday, May 20, 2022. RESTROOMS: Restrooms are clean, sanitary, and in operating condition. The common bathroom wasobserved with appropriate signs, and stocked with paper towels. Hand washing signs were posted in the common bathroom. COMMON SPACES: At the time of the visit, furniture, walls, and flooring were observed to be in good condition. The LPA observed infection control posters in the in the hallway. All required posters were visible.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

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: BLYTHE STREET ELDERLY CARE	FACILITY NUMBER: 197609542
	VISIT DATE: 05/17/2022

NARRATIVE

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OUTDOOR: The outdoor area has a patio area with outdoor furniture and umbrella for residents and family members to meet. There were no open bodies of water visible. The LPA spoke with the facility administrator about removing debris from the patio area, and against the storage room/garage. Although there is a shade patio umbrella available, the shade umbrella was closed. The LPA advised the administrator to open the patio umbrella to provide additional shade for residents. The administrator will send pictures of the backyard area free of debris. Garage area: Emergency food was found in two areas within the garage. The LPA advised the administrator to have all emergency food in in one area in the garage. Administrator will send picture of emergency food to LPA by Friday, May 20, 2022.

INFECTION CONTROL: During today’s visit, the LPA spoke with the administrator regarding the facility’s infection control practices. The facility has items for symptom screening, temperature checks, and sanitation, however these items are placed away from the reach of residents and are found in the kitchen.

No deficiencies cited at this time. Exit interview conducted with facility representatives. Signatures were obtained. The report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 05/17/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/17/2022

LIC809 (FAS) - (06/04)

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