197610375-6-14-2023-31-AS-LQLY-CSSTPP-20230614145440

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610375
Report Date: 06/14/2023
Date Signed: 06/14/2023 02:55:15 PM

Document Has Been Signed on 06/14/2023 02:55 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	ELITE RETIREMENT RESIDENCE		FACILITY NUMBER:	197610375
ADMINISTRATOR:	BERKOWITZ,DENISE		FACILITY TYPE:	740
ADDRESS:	6900 ROYER AVENUE		TELEPHONE:	(818) 640-2475
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 0	DATE:	06/14/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:41 AM
MET WITH:	Eli Zaken & Denise Bedrkowitz		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) LaQueena Lacy arrived at the facility on 06/14/2023 at 10:41AM to conduct an announced Pre-Licensing visit and met with Licensee Eli Zaken and Administrator Denise Berkowitz. Entrance Interview conducted with both parties and explained the purpose of today’s visit, is to inspect the facility and ensure compliance with rules and regulations of California Code of Regulations, Title 22, Division 6.

Today's site visit consisted of the LPA and Licensee toured the physical plant at 10:57AM inside and outside the following was observed: The facility has one main entrance being used, the facility is a single-story building with five (05) bedrooms three (03) bathrooms, and an office space with an adjacent space (bathroom, closet, etc.) designated for live-in staff. The facility fire clearance is granted for four (04) ambulatory, one (01) non-ambulatory and (01) bedridden resident. The facility temperature observed to be in range of 70 degrees Fahrenheit (F).

Kitchen: At 11:02AM, LPA observed the kitchen to be clean and free from obstruction. Appliances observed

to be in good repair and functional. The refrigerator currently is not operational, per Licensee it was purchased in October of 2022, and they have a service repair date for 06/15/2023. Licensee will inform LPA of outcome by email on 06/15/2023. At 11:09AM, LPA observed toxins, and cleaning supplies locked and inaccessible to residents stored in the first bottom cabinet when entering the kitchen. Sharps observed at 11:12AM to be stored locked and inaccessible in a bottom cabinet to the right of the toxins. The facility also has a cabinet in the kitchen storing additional emergency supplies. LPA observed a cabinet storing the emergency food, dry food, canned goods, and vegetable. A first alert fire extinguisher was purchased on 06/14/2023 form Costco, additional fire extinguishers are located on the wall throughout the facility. Adjacent to the kitchen exit door is an adjoined outside space that is connected to the next-door neighbors house with access to their home, per the licensee this area will be inaccessible to residents in care.

Continued on 809C.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: ELITE RETIREMENT RESIDENCE	FACILITY NUMBER: 197610375
	VISIT DATE: 06/14/2023

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Medications: At 11:14AM the medication cabinet located above the toxins were observed to be locked and inaccessible to residents located in the kitchen. LPA observed the First Aid Kits and Manual stored in a cabinet in the kitchen.

Bedrooms: At 11:24AM LPA inspected (05) bedrooms. Bedrooms observed to be clean and appropriately furnished and equipped with adequate lighting and bedroom furniture. Window screens observed during inspection to be in good repair. Appropriate closet space observed.

Bathroom: At 11:38AM LPA observed (03) bathrooms to have non-skid strips and mat with appropriate grab bars installed in shower and around toilet. At 11:43AM hot water was tested and measured in range between 117.5 and 118.2degrees F. The telephone phone number listed for the facility is operational and functioning.

Living/dining room and common areas: Office: At 11:52AM LPA observed a storage closet near bedroom number 5 to be storing extra linens, towels, incontinent supplies, personal care items and PPE. During the inspection LPA observed a room labeled office that will be storing resident and staff files etc. Adjacent to the office is another room labeled employees only locked and inaccessible to resident that will is designated for the live in staff. The area has a closet space, full bathroom and space designed for sleeping. At 11:58AM the common areas (living room, dining areas) were observed to be appropriately furnished and lighting is adequate with comfortable furniture for seating which was observed to be in good repair. There is an activity table located in the dining room (puzzles, games, books etc.) equipped with activities ready for use. Night lights are located throughout the facility for additional lightning. At 12:05PM the laundry room was observed to be locked and inaccessible to resident to be clean and clear from debris and obstruction. At 12:09PM LPA observed the outside and surrounding area of the facility to be clean and clear from debris and obstruction. The facility has an owing with table and chairs for lounging with a space designated with additional table and chairs for lounging, all furniture observed to be in good repair. The back yard exit gate is self-latching and functioning properly. No bodies of water observed on the property. The facility has an attached garage observed to be locked and inaccessible to residents to be storing personal items. During the inspection LPA observed a gas grill in the back yard, due to the facility currently not having residents, the licensee was advised to put in a secure area inaccessible to residents. Per licensee they will ensure safety measure to ensure residents safety by enclosing or removing from the property before obtaining their first resident. Licensee will inform LPA in writing of the improvements made. At 12:14PM the facility carbon monoxide/smoke detector alarms were tested and observed to be hardwired and interconnected to be operational and functioning properly.

Continued on 809C.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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: ELITE RETIREMENT RESIDENCE	FACILITY NUMBER: 197610375
	VISIT DATE: 06/14/2023

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Component III was conducted with the licensee and administrator at 12:18PM.

The facility currently is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB) and you will be notified by the CAB Analyst when your license has been approved.

Exit interview was conducted with Licensee Eli Zaken and a copy of this report was provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: LaQueena Lacy	TELEPHONE: (818) 661-0002
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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