197609932-4-1-2025-29-AS-SURA-DFBMKW-20250401094123

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609932
Report Date: 02/06/2025
Date Signed: 04/01/2025 09:43:11 AM

Document Has Been Signed on 04/01/2025 09:43 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	KAREN'S SENIORS CARE HOME, INC.		FACILITY NUMBER:	197609932
ADMINISTRATOR/ DIRECTOR:	ZINKOFSKY, BRANDON		FACILITY TYPE:	740
ADDRESS:	17610 HAYNES STREET		TELEPHONE:	(818) 205-3820
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/06/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:10 AM
MET WITH:	Brandon Zinkofsky		TIME VISIT/ INSPECTION COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Sandra Urena arrived at the facility unannounced to conduct a required annual inspection at 10:05 a.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Brandon Zinkofsky arrived at 11:30 a.m.

The LPA and the staff 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: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 76 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The two (2) fire extinguishers were fully charged and were last serviced on 01/21/2025. The LPA observed required postings throughout the common space.

KITCHEN: Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The hot water temperature measured at 117.8 degrees Fahrenheit. The washer and dryer are located in a room adjacent to the kitchen. Cleaning supplies and disinfectants are kept in locked cabinet.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six designated residents’ rooms and one staff room. A linen and towels closet is located in the hallway.

BATHROOMS: Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured in the restrooms was recorded at 117.8 degrees Fahrenheit.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. Passages were clear of obstructions. No bodies of water were noted.

Continues on LIC 809C...

Kasandra Lopez	TELEPHONE: (818) 596-4343
Sandra Urena	TELEPHONE: 747-230-3919
	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

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

FACILITY NAME: KAREN'S SENIORS CARE HOME, INC.	FACILITY NUMBER: 197609932
	VISIT DATE: 02/06/2025

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RECORDS: Records review began at 12:30 p.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 01:55 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate 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 LPA reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Certificate of Liability

Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 02/06/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/06/2025

LIC809 (FAS) - (06/04)

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