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Department of
SOCIAL SERVICES
Community Care Licensing
FACILITY EVALUATION REPORT
Facility Number:
197609763
Report Date:
08/09/2024
Date Signed:
08/09/2024 01:22:49 PM
Document Has Been Signed on
08/09/2024 01:22 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
N LA & CEN COA AC/SC
,
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:
08/09/2024
TYPE OF VISIT:
POC
UNANNOUNCED
TIME BEGAN:
10:57 AM
MET WITH:
EILENE KRAKOVER- Administrator
TIME COMPLETED:
01:30 PM
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LPA Mariana Agban conducted a Plan of Correction (POC) Visit subsequent to citations issued during the Complaint 31-AS-20230703161605 conducted on 07/22/24. LPA Agban met with Administrator Eilene Krakover. An entrance interview was conducted.
87468.1(a) & 87468.1(a)(8) -
Personal Rights of Residents
POC:
Administrator agreed to email LPA a statement of understanding this section of CCR by the POC date and
Administrator will hire a licensed vendor to train all staff on Basic Services Regulations.
POC Date: 07/22/24 / Correction Completed /
POC Cleared on 08/01/24. LPA obtained copies of the statement of understanding and staff training certificates.
87625 (b)(3) -Managed Incontinence
POC: Administrator agrees to hire a licensed vendor to train all staff on
Managed Incontinence
POC Date: 07/22/24 / Correction Completed /
POC Cleared on 08/01/24. LPA obtained copies of staff training certificates.
87555(b)(5) - General Food Services
POC: Administrator agrees to hire a licensed vendor to train all staff on General Food Services
POC Date: 07/22/24 / Correction Completed /
POC Cleared on 08/01/24. LPA obtained copies of staff training certificates.
87468.1(a)(11) - Personal Rights of Residents
POC: Administrator agrees to hire a licensed vendor to train all staff on Personal Rights
POC Date: 07/22/24 / Correction Completed /
POC Cleared
on 08/01/24
LPA obtained copies of staff training certificates.
SUPERVISOR'S NAME:
Eva Miller
TELEPHONE:
(818) 596-4373
LICENSING EVALUATOR NAME:
Mariana Agban
TELEPHONE:
818-738-4525
LICENSING EVALUATOR SIGNATURE:
DATE:
08/09/2024
I acknowledge receipt of this form and understand my
licensing
appeal rights as
explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE:
08/09/2024
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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