197609763-7-10-2024-31-AS-NRED-D72V9X-20240710161503

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609763
Report Date: 07/10/2024
Date Signed: 07/10/2024 04:16:07 PM

Document Has Been Signed on 07/10/2024 04:16 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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BLUE SKIES RANCH		FACILITY NUMBER:	197609763
ADMINISTRATOR:	KRAKOVER, EILENE		FACILITY TYPE:	740
ADDRESS:	6061 SHIRLEY AVE		TELEPHONE:	(818) 730-4182
CITY:	TARZANA	STATE: CA	ZIP CODE:	91356
CAPACITY:	6	CENSUS: 4	DATE:	07/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Eilene Krakover		TIME COMPLETED:	04:25 PM

NARRATIVE

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At 1:10 p.m. on 07/10/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with administrator and disclosed the reason for the visit. LPA and administrator toured the facility inside and out.

The facility was last visited on 03/05/24 for a complaint visit. It is a single story building with four (04) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) nonambulatory residents, of which one (01) may be bedridden. The facility serves residents with dementia. Approved hospice waivers for six (06).

At the main entrance, LPA observed a maintained front area and driveway. Postings were observed inside for confidential complaint contacts, emergency contacts, Ombudsman contacts, rights of family and resident councils, personal rights, employee rights, facility license, and facility sketch with evacuation routes clearly labelled.

Walls, floors, windows, screens, and blinds were clean and in good repair. At approximately 1:30 p.m. LPA measured the room temperature to be 72 degrees Fahrenheit. A storage room was locked and contained confidential files and medications. The living room contained board games, activities, an appropriately grated fireplace, puzzles, and a television. Three (03) residents were observed eating a meal together.

LPA observed an adequate supply of perishable and non-perishable foods in the kitchen. At approximately 1:45 p.m. the refrigerator and freezer temperatures were measured to be 38 degrees Fahrenheit and -2.2 degrees Fahrenehit. The stove hood was clean. Appliances were in good condition. Sharps were locked below the counter. Cleaning solutions were locked in a cabinet near the washer and dryer. A laundry area near the kitchen contained a washing machine and dryer in working order. Detergents were locked in a cabinet next to the appliances.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

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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Document Has Been Signed on 07/10/2024 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE SKIES RANCH	FACILITY NUMBER: 197609763
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.618(c)(3)

Other Provisions

(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in two (02) out of two (02) employees which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 07/31/2024
	Plan of Correction
1 2 3 4	Licensee to submit POC by due date showing all staff have renewed CPR/First Aid certifications.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE SKIES RANCH	FACILITY NUMBER: 197609763
	VISIT DATE: 07/10/2024

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The facility has four (04) bedrooms. Three (03) bedrooms are private and one (01) is shared. All bedrooms contained a chair, lamp, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #2 had a sign posted for “No smoking – Oxygen in Use”. Bedroom #1 and Bedroom #3 have private bathrooms. There is a shared bathroom outside of Bedroom #2 and a half bathroom near the laundry area. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 2:10 p.m. LPA measured the water temperature in the shared bathroom to be 108.9 degrees Fahrenheit.

LPA observed a covered patio area in the rear of the facility. A mosquito net covered the sliding glass door separating the living room from the outside area. The patio was shaded and contained furniture in good condition and had a gardening area. The emergency exit path and ramp leading out were free of tripping hazards. The exit gate was unlocked with an inward facing, self-closing latch. The pool in the back yard was fenced, locked, and inaccessible. A storage shed in the area contained gardening supplies and was also inaccessible. Auditory alarms were turned on and functioning. At approximately 2:30 p.m., smoke and carbon monoxide detectors were tested and operational. At approximately 3:00 p.m. LPA observed a fully charged fire extinguisher in the laundry area.

At 3:05 p.m. LPA reviewed resident and personnel files. Two (02) out of two (02) staff had First Aid/CPR certifications which had expired on 06/08/2024. A deficiency is issued on the attached LIC 809-D page.

No immediate health and safety risks were observed during today’s visit.

Exit interview conducted. Appeal rights discussed. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/10/2024

LIC809 (FAS) - (06/04)

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