197609771-2-23-2022-29-AS-EPEI-CBWVEM-20220223152235

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609771
Report Date: 02/23/2022
Date Signed: 02/23/2022 03:23:16 PM

Document Has Been Signed on 02/23/2022 03:23 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:	ETERNAL LIFE SENIOR CARE FACILITY		FACILITY NUMBER:	197609771
ADMINISTRATOR:	AVETIKYAN, OLGA		FACILITY TYPE:	740
ADDRESS:	8112 CROSNOE AVENUE		TELEPHONE:	(818) 988-7878
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91402
CAPACITY:	6	CENSUS: 5	DATE:	02/23/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Olga Avetikyan, Administrator		TIME COMPLETED:	03:30 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	At 1:45 p.m., Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. LPA was greeted and screened by staff, Elya Poghosyan. At 2:06 p.m., the Administrator arrived at the facility. This annual had a specific emphasis on infection control practices and procedures. At 2:18 p.m., LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREAS: LPA observed common area to be relatively clean and properly furnished. LPA observed the fire extinguisher to be fully charged and purchased on 06/01/2021. Flashlights were observed throughout the facility. Signs are posted throughout facility to promote handwashing, cough/sneeze etiquette, and physical distancing. At 2:34 p.m., fire alarms and carbon monoxide detectors were tested and functioning properly. BEDROOMS: LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with a grab bar and non-skid mats. At 2:35 p.m., hot water measured at 109.9-degree Fahrenheit. Night lights were present in the hallways and passages. OUTDOOR SPACE: At 2:21 p.m., LPA observed the backyard, which has a covered outdoor area for resident use. There is a gate at the front of the facility designated for an emergency exit. Passageways were free and clear from obstruction. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

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: ETERNAL LIFE SENIOR CARE FACILITY	FACILITY NUMBER: 197609771
	VISIT DATE: 02/23/2022

NARRATIVE

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Contiued from LIC 809.

KITCHEN: At 2:23 p.m., LPA observed the kitchen/dining area. Knives are stored in a locked cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 2:33 p.m., hot water measured at 105.2-degree Fahrenheit. Medications and first aid kits are located in a locked kitchen cabinet.

STORAGE: The storage room is next to the kitchen. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the storage room. The laundry units are located inside the storage room.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station.
LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Between 2:08 p.m. - 2:18 p.m., LPA conducted Infection Control mitigation module with Administrator.

The following recommendations were made:
- Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department.

No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report will be provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 02/23/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/23/2022

LIC809 (FAS) - (06/04)

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