197609771-3-28-2024-29-AS-EPEI-D3SRVX-20240328132215

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609771
Report Date: 03/28/2024
Date Signed: 03/28/2024 01:22:59 PM

Document Has Been Signed on 03/28/2024 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
WOODLAND HILLS N.ASC, 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: 3	DATE:	03/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:57 AM
MET WITH:	Viktorya Hayrapetyan, staff		TIME COMPLETED:	01:30 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) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 10:57 a.m., the LPA met with staff and explained the reason for the visit. At 11:15 a.m., staff Viktorya Hayrapetyan arrived at the facility. The Administrator was not available during the time of the visit and authorized staff Viktorya H. to sign the report. At 11:50 a.m., the LPA, along with staff, 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. KITCHEN: The LPA observed the kitchen and dining area. Knives are stored in a locked kitchen cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 11:51 a.m., hot water measured at 105.2-degree Fahrenheit. Laundry units, cleaning solutions, chemicals and hazardous items were inaccessible and locked away inside the staff/ storage room. Emergency water was also located in the staff/ storage room. First aid kit was observed in the kitchen. Medications are located in a locked kitchen cabinet. OUTDOOR SPACE: At 11:53 a.m., the LPA observed the back patio which has a covered outdoor area for resident use. Passageways were free and clear from obstruction. There are no bodies of water on the premises. There is a gate at the front of the facility designated for an emergency exit. BEDROOMS: The facility is a single-story residential home with five (5) bedrooms, four (4) for resident use and one (1) for staff use and three (3) bathrooms. The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. At 11:54 a.m., the LPA observed inoperable auditory devices in all resident room doors leading to the outside. Upon observation, staff stated that the auditory devices will be replaced with operable ones or fixed. Continued on LIC-809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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 03/28/2024 01:22 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ETERNAL LIFE SENIOR CARE FACILITY	FACILITY NUMBER: 197609771
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/28/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(a)

Maintenance and Operation

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above in all auditory devices attached to resident bedrooms door were not in operation/ good repair during the time of the visit which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 04/10/2024
	Plan of Correction
1 2 3 4	The Licensee stated that the auditory devices will be either replaced with operable ones or be fixed by due date and provide proof to LPA.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ETERNAL LIFE SENIOR CARE FACILITY	FACILITY NUMBER: 197609771
	VISIT DATE: 03/28/2024

NARRATIVE

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RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. Starting 11:55 a.m., hot water measured at 108.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. Signs are posted throughout the facility restrooms to promote handwashing.

COMMON AREAS: The LPA observed common areas to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last purchased on 03/28/2024. At 12:00 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly. Facility telephone was observed during the time of the visit. Flashlights and night lights were observed throughout the facility.

During the time of the visit, the LPA obtained copies of the following: Emergency Disaster Plan, Infection Control Plan, LIC 308, and LIC 500.

The Administrator’s certificate is active and expires on 09/01/2024.

Due to time constraints, the LPA will return to complete the annual at a later date.

Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8 and California Health and Safety Code the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 03/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/28/2024

LIC809 (FAS) - (06/04)

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