197610456-8-20-2024-31-AS-LNCA-D8BUD7-20240820152904

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610456
Report Date: 08/20/2024
Date Signed: 08/20/2024 03:29:11 PM

Document Has Been Signed on 08/20/2024 03:29 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.RO, 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: 4	DATE:	08/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:24 PM
MET WITH:	Lily Balasantan- Designee		TIME COMPLETED:	04:00 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) Leslie Ngo-Castaneda conducted an annual required visit and inspection of the facility. LPA met with staff, Marina Sarsyan and explained the reason for the visit. Approximately, around 1:40 PM designee Lily Balasantan and was explained for the reason of the visit. At 1:45 PM, with the assistance of designee, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are operational. There are carbon monoxide detectors that functions properly. The fire extinguisher is in the kitchen. The charge date is 7/17/2024. During the visit the facility is at 73 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden; bedroom #4 approve for bedridden; hospice waiver for five (5). Kitchen: The kitchen appliances and fixtures were functional. The kitchen has a working gas stove, faucet, freezer, refrigerator, and microwave. LPA found enough at least two (2) days perishable and seven (7) days non-perishable food at the facility that is properly stored. Frozen foods are wrap, dated, and stored properly as well. Knives were stored in a locked drawer in the kitchen. Office space is in the living area beside the common area. Properly labeled medications were locked in the cabinets in the office station. Bedrooms: There were four (4) bedrooms designated for residents. Four (4) of the that are in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Room #1 and #4 are properly furnished are shared room. Bedroom #2 and bedroom #3 are private use and is currently vacant. Bathrooms: There are two (2) bathrooms designated for residents' and staff use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 109.8 degrees Fahrenheit for bathroom #1 located in the hallway across bedroom#3. Bathroom #2 measured 107.3 degrees Fahrenheit in bedroom #1. Towels and washcloths are not shared. There was enough clean linen available in the cabinets in the hallway. Continue to LIC 809-C

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

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.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BREATH OF SUNSHINE	FACILITY NUMBER: 197610456
	VISIT DATE: 08/20/2024

NARRATIVE

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Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit. Residents dining table fits enough for six (6).

Surrounding Grounds: Entry and exits were free of obstruction. There was furniture appropriate for outdoor use. The outdoor area was free of hazards. The laundry area and detergents are located by the locked laundry room in between the dining room and living room that are kept secured. The facility does not have a swimming pool or body of water. The garage is detached and is used for storage for incontinence for residents.

Resident Files: LPA conducted a file review of resident records to ensure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to ensure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records (MMR) were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, no deficiencies observed during the visit. Exit interview conducted and a copy of the report issued.

SUPERVISOR'S NAME: Nichelle Gillyard	TELEPHONE: (818) 596-4370
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda	TELEPHONE: (818) 214-9900
LICENSING EVALUATOR SIGNATURE:	DATE: 08/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/20/2024

LIC809 (FAS) - (06/04)

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