197610456-8-9-2023-31-AS-APAA-CUJQEK-20230809120628

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610456
Report Date: 08/09/2023
Date Signed: 08/09/2023 12:07:03 PM

Document Has Been Signed on 08/09/2023 12:07 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:	BREATH OF SUNSHINE		FACILITY NUMBER:	197610456
ADMINISTRATOR:	SIMONIAN,RUZANNA		FACILITY TYPE:	740
ADDRESS:	8627 NORWICH AVE		TELEPHONE:	(323) 683-8080
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY:	6	CENSUS: 0	DATE:	08/09/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Ruzanna Simonian, Administrator		TIME COMPLETED:	12:30 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	At 10:00am Licensing Program Analysts (LPAs), Angela Panushkina and Christopher Alemoh conducted an announced Pre-Licensing visit to the above facility and met with Applicant/Licensee, Ruzanna Simonian. Fire Clearance was approved on 07/10/2023 for a maximum capacity of six (6) residents, of which five (5) Non-Ambulatory and one (1) bedridden residents. Hospice waiver for five (5) residents was approved on 07/24/23. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPAs touring the physical plant inside and outside and observed the following: KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven and sink. At 10:10am, LPAs observed adequate supplies of perishable and nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen drawer and inaccessible to residents. Fire Extinguisher was last purchased on 07/08/23. BEDROOMS: There are four (4) bedrooms designated for client use. All bedrooms are furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Auditory alarms were tested and observed to be operational. BATHROOMS: At 10:25am LPAs observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. The hot water temperature measured at 115.°F. LPAs observed appropriate grab bar and had non-skid mat. Continue on LIC809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

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: BREATH OF SUNSHINE	FACILITY NUMBER: 197610456
	VISIT DATE: 08/09/2023

NARRATIVE

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COMMON AREAS: The facility maintains a comfortable temperature at 75°F. The living room and dining appeared clean and were properly furnished. No obstructions and or tripping hazards throughout the facility.

MEDICATION and FILES: The medication will be kept in a locked cabinet located in the kitchen. The facility staff/resident files will be kept in a file cabinet by the living room area.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. At 10:50am they were tested and observed to be operational.

LAUNDRY ROOM: The laundry room is located outside by the patio. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

SURROUNDING GROUNDS: In the back of the facility has sufficient yard space. LPAs observed appropriate outdoor furniture, with a covered shaded area for clients. The backyard is fenced. LPAs discussed the importance of maintaining the care and supervision to meet the needs of clients. There are no bodies of water

GARAGE: The garage is detached and currently being used for storage. LPAs observe the garage locked and inaccessible to residents in care.

Component III was conducted with the Administrator.

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

Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4341
LICENSING EVALUATOR NAME: Angela Panushkina	TELEPHONE: 747-230-3364
LICENSING EVALUATOR SIGNATURE:	DATE: 08/09/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2023

LIC809 (FAS) - (06/04)

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