197610467-12-18-2023-31-AS-TSMH-CYMSVS-20231218131313

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610467
Report Date: 12/18/2023
Date Signed: 12/18/2023 01:13:59 PM

Document Has Been Signed on 12/18/2023 01:13 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:	ELEGANT SENIOR LIVING ENCINO		FACILITY NUMBER:	197610467
ADMINISTRATOR:	SAGAL, DANIEL		FACILITY TYPE:	740
ADDRESS:	16710 MAGNOLIA BLVD		TELEPHONE:	(818) 213-7324
CITY:	ENCINO	STATE: CA	ZIP CODE:	91436
CAPACITY:	6	CENSUS: 5	DATE:	12/18/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Daniel Sagal		TIME COMPLETED:	01:13 PM

NARRATIVE

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Licensing Program Analyst (LPA) Tihesha Smith conducted an announced pre-licensing visit with administrator Daniel Sagal. Identification of the Applicant/Administrator was verified by photo ID.

The facility has a capacity of six (6). Application received for six (6) Non-ambulatory residents.

LPA conducted a tour of the physical plant at approximately 10:50 am to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common areas were observed for the ability to safely serve the needs residents. These included the living room, dining room combination, kitchen, and family area. The common areas were checked for cleanliness and furniture was checked for functionality. Common areas observed to be clean, sanitary and have adequate seating for residents.

LPA reviewed the food service areas, food storage and supply (perishable and nonperishable foods). The
kitchen food supply was observed and sufficient for the five (5) residents currently residing there. Two (2) days of perishable food observed. The freezer is stocked with meats and frozen foods. Sharps are stored in kitchen drawer. Sharps observed to be locked and inaccessible to residents in care. First aid kits stored in upper cabinets in living room. Toxins are stored and locked under kitchen sink and observed to be locked and inaccessible to residents.

There are two (2) fire extinguishers in the facility: One (1) attached to the kitchen wall and one (1) attached to wall in family area. Both fire extinguishers observed to be charged.

Laundry room is located at the back of the kitchen.
(Cont. to 809)

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

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: ELEGANT SENIOR LIVING ENCINO	FACILITY NUMBER: 197610467
	VISIT DATE: 12/18/2023

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(Cont. from 809C)

The facility has a total of six (6) bedrooms, six (6) in room bathrooms for residents in care, and one (1) main bathroom. There is also an office with an additional refrigerator stocked with perishable foods.

The resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, and blankets. Extra linen stored in each room.

Each bathroom has posted “wash your hands” signs and the following items available: hand soap, paper
towels, and trash cans. The hot water temperature was measured from empty room and main bathroom
The water temperature range was between 112.8 and 117.3 -degrees Fahrenheit.

Backyard has the following: Covered patio with tables and chairs. Patio furniture observed to be in good repair with adequate seating for residents. Two (2) sheds: used for emergency food and equipment storage. Sheds observed to be locked an inaccessible to residents in care.

No Garage at the facility

Smoke detector/carbon monoxide detector were tested and operable at time of visit.

Facility grounds were free of hazards.

At time of visit this facility is ready to be licensed. A copy of this report will be forwarded to the Centralized Applications Bureau (CAB).

Exit Interview Conducted /Copy of the Report Issued

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Tihesha Smith	TELEPHONE: 818-307-6280
LICENSING EVALUATOR SIGNATURE:	DATE: 12/18/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/18/2023

LIC809 (FAS) - (06/04)

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