197609763-7-22-2022-31-AS-MCAA-CGKKY3-20220722081827

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609763
Report Date: 07/19/2022
Date Signed: 07/22/2022 08:18:33 AM

Document Has Been Signed on 07/22/2022 08:18 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., 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:	07/19/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:45 AM
MET WITH:	Eilene Krakover		TIME COMPLETED:	02:45 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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with the administrator, Eilene Krakover and explained the reason for the visit. At 11:50am, with the assistance of the administrator, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are hardwired and interconnected. There is a carbon monoxide detector in the hallway that functions properly. The internal temperature is maintained at 73 degrees. The fire extinguisher is fully charged to date. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility properly stored. Knives were stored in a locked drawer in the kitchen. Cleaning supplies were maintained and kept locked and inaccessible under the kitchen sink. Bedrooms: There are three (3) bedrooms designated for residents' use. All three bedrooms, in use by residents, were were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are three and a half (3 1/2) bathrooms designated for residents' use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 105 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. There is a storage space, that is locked at all times, where records, medications, client and PPE supplies are maintained.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE SKIES RANCH	FACILITY NUMBER: 197609763
	VISIT DATE: 07/19/2022

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
26
27
28
29
30
31
32

Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The backyard has a swimming pool, that is fenced around it's parameters with a five foot gate. The fence is locked and inaccessible. The outdoor area was free of hazards.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit.

Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 07/19/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/19/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2