197610375-7-31-2024-31-AS-NRED-D7PPZZ-20240731114621

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610375
Report Date: 07/31/2024
Date Signed: 07/31/2024 11:46:46 AM

Document Has Been Signed on 07/31/2024 11:46 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 S.ASC, 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:	07/31/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Eli Zaken		TIME COMPLETED:	12:00 PM

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At 9:15 a.m. on 07/31/24, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with the licensee and disclosed the reason for the visit. LPA and licensee toured the facility inside and out.

The facility was last visited on 06/14/23 for a prelicensing visit. It is a single story building with six (06) bedrooms, four (04) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for six (06) residents, of which four (04) may be ambulatory and two (02) may be non-ambulatory with one (01) bedridden in Bedroom #5. Approved hospice waivers for three (03).

At the main entrance, LPA observed a maintained front yard. Postings for resident rights, confidential complaint contacts, ombudsman contacts, and facility sketch and license were observed near the front. A binder contained additional required postings. LPA observed an adequate supply of perishable and non-perishable foods in the refrigerator. At 9:35 a.m. the refrigerator and freezer temperatures were measured to be 37 and 0 degrees Fahrenheit, respectively. The stove hood was clean. Appliances were new and in good condition. Sharps, cleaning solutions, and a complete first aid kit were locked below the counter. Medications were locked above the counter top. At approximately 9:45 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It had a receipt posted from 06/23/24. A washing machine and dryer were located near the kitchen. Both were in working order. Detergents were locked in the laundry room with the appliances. Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:55 a.m. LPA measured the room temperature to be 74 degrees Fahrenheit.

At approximately 10:00 a.m., the licensee explained that there are zero (00) staff and zero (00) currently at the facility. The facility has yet to admit their first resident. Only the licensee’s family member and their private caregiver were observed at the facility. The facility has six (06) bedrooms. One (01) bedroom is designated as a staff room. The staff room was free of hazards. Bedrooms contained beds with adequate bedding and sufficient storage space. All furnishings were clean and in good condition.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

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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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: ELITE RETIREMENT RESIDENCE	FACILITY NUMBER: 197610375
	VISIT DATE: 07/31/2024

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The facility has four (04) bathrooms. Bathrooms contained liquid soap, paper towels, trash can, grab bars near the toilet and shower, and a non-skid surface in the shower. At approximately 11:00 a.m. LPA measured the water temperature to be 108.8 degrees Fahrenheit in the front bathroom.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. The ramp leading out from the bedridden room was free of hazards and had secure handrails. The emergency exit path was free from obstructions. Exit gates were unlocked with self-closing latches. Evacuation routes were posted. At approximately 11:15 a.m., smoke and carbon monoxide detectors were tested and operational.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed during today’s visit.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2024

LIC809 (FAS) - (06/04)

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