197610102-11-23-2021-31-AS-NRED-C92TDW-20211123133901

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610102
Report Date: 11/23/2021
Date Signed: 11/23/2021 01:39:41 PM

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:	ALLEVIATE CARE		FACILITY NUMBER:	197610102
ADMINISTRATOR:	ESTRADA, LOURDES M		FACILITY TYPE:	740
ADDRESS:	20930 GAULT STREET		TELEPHONE:	(818) 378-2772
CITY:	CANOGA PARK	STATE: CA	ZIP CODE:	91303
CAPACITY:	6	CENSUS:	DATE:	11/23/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:58 AM
MET WITH:	Edgar Ghazaryan		TIME COMPLETED:	12:19 PM

NARRATIVE

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On 11/23/2021 at 09:58 AM, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual visit. LPA met with Staff, and Administrator joined later. LPA disclosed the reason for the visit. LPA conducted the visit under the Infection Control Domain of Licensing’s Compliance and Regulatory Enforcement (CARE) Tools.

The census of residents was 7

Facility has a Mitigation Plan, approved by the Regional Office, to mitigate the spread of COVID-19 in the facility.

At approximately 10:07AM, LPA inspected the inside of the facility.

ENTRY:

LPA noted the entrance ramp and stairs to be in good condition. Outside of the front door, LPA observed two COVID-related signs: No Visitors Allowed and instructions for Special Visitors. Upon entry to the facility, staff took LPA’s temperature and directed LPA to sign Visitor's Log. Staff was wearing a mask to prevent spread of COVID-19. LPA observed one central entry point designated for the screening. LPA saw a screening station which contained hand sanitizer, 2 digital thermometers N95 masks, surgical masks, and disinfecting bleach wipes.

Once inside, LPA observed Emergency Evacuation route posted, as well as Personal Rights poster and a Confidential Complaint hotline poster. Administrator showed LPA the facility’s designated visitation area at the front.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALLEVIATE CARE	FACILITY NUMBER: 197610102
	VISIT DATE: 11/23/2021

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Kitchen: As staff sanitized the area, LPA observed two handwashing signs posted by the kitchen sink, along with liquid soap and a metal paper towel dispenser. Below the sink was a locked cabinet containing cleaning supplies.
Bathrooms: LPA observed liquid soap, metal paper towel dispensers, and two handwashing signs in 3 out of 3 bathrooms. 2 out of 3 bathrooms had trash cans with tight-fitting lids. LPA measured water temperature in the bathroom directly across from the kitchen to be 105.1 degrees Fahrenheit.

Bedrooms: LPA observed bedrooms to be in good condition. LPA detected no odors or signs of vermin. LPA tested room temperature. Thermometer read 78.3 degrees Fahrenheit. Shared bedrooms #1 and #6 contained beds which were 6 feet apart allowing appropriate social distancing for residents.

Common Areas: LPA observed a resident watching television. Seating accommodations in the living room are spaced so residents remain 6 feet apart. Administrator noted high traffic common areas and high touch surfaces are cleaned and disinfected at least once a day. Walls, floors, furniture, windows, and curtains were all clean and in good repair.

Outside and Garage: At approximately 11:15 AM, LPA and Administrator toured outside and the garage. LPA heard and saw 2 audio alarms attached to the front door and side exit of the facility. In the garage, LPA observed sufficient supplies of gloves, N95 masks, surgical masks, face shields, and gowns. LPA also observed hazardous chemicals locked away in garage as well.

Mitigation Plan: At approximately 10:38 AM, Administrator and LPA reviewed the facility’s Mitigation Plan.
Administrator assured all residents have been notified about facility infection control policies. Administrator also noted the facility has procedures for when to test staff and residents to monitor the spread of the virus and mitigate outbreaks, and the facility tests staff during hiring process and residents before admission for COVID-19. The Facility checks supplies daily to make sure that all resident rooms and common areas have tissues and hand sanitizer, and all sinks have liquid soap, and paper towels. The Facility also has 2 phones for residents’ use. In the event of a staffing shortage, Administrator provides assistance, and he has access to a staffing agency. Administrator is also the infection control lead in charge of preparedness planning and integrating local Department of Public Health, California Department of Public Health and Center for Disease Control guidance to all residents and staff.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ALLEVIATE CARE	FACILITY NUMBER: 197610102
	VISIT DATE: 11/23/2021

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At approximately 10:55 AM, LPA and Administrator discussed facility procedures in the event of a COVID positive resident. Administrator stated the facility is able to designate a single-person room with a closed door to isolate symptomatic and/or asymptomatic exposed residents. Staff are able to serve all meals and deliver medications to residents in isolation. Facility developed plan to ensure appropriate cleaning of isolation rooms.

Mitigation Plan Review: Facility follows many aspects of the Mitigation Plan

LPA reminded Administrator to maintain a symptom screening log (+/- temperature and symptom check) for all staff, residents, and visitors, in which the facility has documented daily temperature and COVID-19 symptom checks, and any changes in condition for staff and residents.

LPA also reminded Administrator to obtain Fit testing for staff working with COVID positive residents.

Exit interview conducted and copy of report emailed to Administrator.

SUPERVISOR'S NAME: Cassandra Harris	TELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 11/23/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/23/2021

LIC809 (FAS) - (06/04)

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