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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610270
Report Date: 04/08/2024
Date Signed: 04/08/2024 01:25:50 PM


Document Has Been Signed on 04/08/2024 01:25 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:SKYVIEW ASSISTED LIVINGFACILITY NUMBER:
197610270
ADMINISTRATOR:HULSE, BREANNAFACILITY TYPE:
740
ADDRESS:18761 BIG CEDAR DRIVETELEPHONE:
(661) 965-4652
CITY:SANTA CLARITASTATE: CAZIP CODE:
91387
CAPACITY:6CENSUS: 2DATE:
04/08/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Breanna HulseTIME COMPLETED:
01:30 PM
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Licensing Program Analysts (LPA) Tuesday Cabiness arrived at the facility to conduct an annual inspection. LPA was greeted by caregiver Paris Davis , who allowed LPA to enter. Administrator Breanna Hulse also greeted LPA; and everyone was informed the reason of the visit. .

A physical plant tour of the facility inside and outside was conducted with Administrator. The following common areas: living, dining, kitchen, resident bedrooms, and bathrooms were inspected to ensure the facility was in compliance with Title 22 Regulations: Kitchen: LPA observed Licensing requirement of (7) day nonperishable, and (2) day perishable, with extra refrigerator in the garage. Food was properly wrapped, and appliances were functional, clean, and in good repair. Chemicals, household supplies, and knives, are stored in the kitchen and laundry room; all were locked and secured. Living/dining: All indoor passageways were free from obstruction; inside temperature was comfortable, with adequate lighting, and all areas were clean and appropriately furnished for resident’s comfort. Bedrooms: The facility has (4) bedrooms for residents; with (2) private and (2) shared; no staff room. All bedrooms were properly furnished and supplied with appropriate bedding and linens. There were sufficient linens observed and available. Bathrooms: There are (2.5); all were clean, with soap and towels, grab bars, and non-skid mats. Hot water measured 107.8 degrees Fahrenheit. Surrounding Grounds: There were no visible hazards; passageways were free from obstruction and gates were easily accessible to open. The facility has outdoor furniture for residents comfort. There are no swimming pools or other bodies of water. All exit doors have locks and alarms; all were operating. Fire extinguisher fully charged. First aid kit furnished fully equipped. Smoke alarms and carbon monoxide detectors were tested and operating properly. Record review: A complete record review of staff and residents were conducted; no errors observed. All Licensing documents observed in files. Training was current and update. Medication review: No errors observed. .

Exit interview and copy of report provided.

SUPERVISOR'S NAME: Troy AgardTELEPHONE: (818) -596-4334
LICENSING EVALUATOR NAME: Tuesday CabinessTELEPHONE: (818) 299-4975
LICENSING EVALUATOR SIGNATURE:
DATE: 04/08/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/08/2024
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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