197609542-6-29-2023-29-AS-SURA-CT9L7L-20230629083029

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609542
Report Date: 06/28/2023
Date Signed: 06/29/2023 08:31:22 AM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 06/29/2023 08:31 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
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: 0	DATE:	06/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Nona Ohanyan		TIME COMPLETED:	12:30 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 inspection at 10:30 a.m. The LPA arrived at the facility and rang the front door bell several times, but there was response. The LPA contacted the Administrator via phone at (323) 947-7005. The LPA spoke with facility Administrator Nona Ohanyan, and explained the reason for the visit. The Administrator stated that no one was at the facility, and they would have to come to open the door for the inspection. The administrator arrived at 11:39 a.m. 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. The facility appeared vacant, and no residents were present at the time of the inspection. The administrator stated that the department was informed of the temporary closure of the facility via email in April 2023, the administrator stated that they are not able run facility due to their job. Per the administrator the residents received the eviction notice on March 1,2023, and the facility has been without residents and closed as of May 1, 2023. The two residents residing at the facility were relocated by their POA’s to live with family members. The facility appeared to in the process of packing up furniture and household items. No residents were residing at the facility during today's visit. There are three bedrooms for residents use. The bedrooms were inspected and one bedroom appeared to be occupied based on the items seen, which were men's clothing. The administrator stated that their family member stays occasionally at the facility to keep it safe. 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: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLYTHE STREET ELDERLY CARE	FACILITY NUMBER: 197609542
	VISIT DATE: 06/28/2023

NARRATIVE

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The administrator stated that they own the property and are in the process of deciding if they want to submit a Change of Ownership Application (CHOW), or relinquish the license, they may rent out the house. Administrator will email to LPA Urena the Eviction Notice served to the residents , and a copy of the formal letter stating the reasons for closing the facility, and dates of closure; the administrator will email the documents by the end of closing day 06/28/2023. The Administrator stated that they will look into paying the current fees due.

LPA Urena advised the administrator of the following:

The annual fees must continue to be paid, or the license may be revoked by the department. As of 06/28/2023, the annual fees are not currently paid.
The administrator must inform the LPA and the CCLD department about any new possible residents, should the administrator decide to readmit residents to the facility. A case management visit would need to be scheduled to ensure all regulations are being met prior to resuming service.
The facility is licensed as a Residential Facility for the Elderly and to provide service to residents, therefore the facility cannot be used as family residence.

No deficiencies cited at this time. Exit interview conducted with administrator. 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: 06/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/28/2023

LIC809 (FAS) - (06/04)

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