197610260-10-27-2023-31-AS-JGTN-CWZSMF-20231027135953

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610260
Report Date: 10/27/2023
Date Signed: 10/27/2023 02:00:36 PM

Document Has Been Signed on 10/27/2023 02:00 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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TELECARE OLIVE HOUSE		FACILITY NUMBER:	197610260
ADMINISTRATOR:	KENOBI, ROBBIE		FACILITY TYPE:	772
ADDRESS:	14149 BUCHER AVE		TELEPHONE:	(747) 999-4232
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY: 16		CENSUS: 16	DATE:	10/27/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:11 AM
MET WITH:	Quisha Castro - Interim Administrator		TIME COMPLETED:	02:00 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) Gary Tan conducted an Annual Required visit and inspection of this facility today and initially met with staff Harout Krboyan and Vanessa Cano and explained the reason for the visit. Interim Administrator Quisha Castro arrived later. At approximately 11:00 AM, a tour of the physical plant was done with the staff. Infection Control: There is only one entrance being utilized at the facility, the front main entrance door. The two (2) side doors are for emergency only. There are required poster posted at the main door. Screening area is located immediately upon entrance in the reception area. All visitors/resident and staff are required to sign. There is also a sign in sheet, hand sanitizer, gloves and masks available. The facility had submitted and approved Mitigation plan and Infection plan. There are hand sanitizers all over the facility. There are signs to wear a mask and other Covid 19 prevention protocol signs were posted outside the doors. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in common bathrooms, elevators and all over the common areas of the facility. The facility have multiple designated visitors' area in the front entrance. The facility has sufficient stock of PPE in the storage room. The facility is fire cleared for sixteen (16) ambulatory residents. This is a short term crisis residential facility. There are fire extinguishers all over the facility and last inspected on 04/26/23. The facility is equipped with sprinkler system. The facility temperatures was set at 73.0°F. The smoke alarm are hard wired and interconnected and last tested on 05/23/23. Fire and sprinkler inspection was done on 05/23/23. There is a carbon monoxide installed in the facility. Fire drill was last done on 10/10/23. Kitchen: The facility has a food waiver and food is being catered. The kitchen is only being utilized for heating food and emergency food storage. The kitchen appeared clean and the appliances and fixtures functional. (continued on LIC 809-C)

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

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 S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TELECARE OLIVE HOUSE	FACILITY NUMBER: 197610260
	VISIT DATE: 10/27/2023

NARRATIVE

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Bedrooms: Personal accommodations in resident bedrooms were observed for safety, privacy and comfort. Random resident rooms were inspected and observed with all required furnishings. There are a total of nine (9) bedrooms in the facility, five (5) on the 2nd floor and four (4) on the ground floor, all except for the two (2) ADA rooms on the ground floor are shared.

Bathrooms: There are six (6) total common bathrooms with shower in the facility. Three (3) on the ground floor and three (3) on the 2nd floor. There are two (2) additional common bathroom for the residents on the ground floor without shower. They were properly supplied and had functional fixtures. Hot water temperature in common bathrooms were checked and measured at a range of 107.8°F to 110.4°F and within the required range.

Common Areas: Common areas, including the activity rooms, lactation room, dining rooms and offices appeared clean and were properly furnished. There are also three (3) laundry rooms in the facility, two (2) are located in the ground floor and one (1) on the 2nd floor. Laundry soap and other cleaning agents were observed locked in the laundry room and janitor's closet. Residents are given individual laundry soap pods upon request.

Surrounding Grounds: Entry/exits were free of obstruction. The outdoor area was clean and free of hazards. There is no body of water in the facility.

Resident Files: LPA conducted a file review of resident records. Resident records appeared complete and updated. Staff Files: LPA also conducted a file review of staff records. Staff files appeared complete and updated.

Medications: The medications were locked in the medication cart, properly labeled and stored in the nurse's station. Medication documentation and implementation appeared to be complete. There is a First aid kit located in the nurse's station.

There is no health and safety issue observed during this visit. Exit Interview Conducted and a Copy of this Report Issued.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Jose Gary Tan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/27/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/27/2023

LIC809 (FAS) - (06/04)

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