<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197690036
Report Date: 06/07/2022
Date Signed: 06/07/2022 11:42:04 AM

Document Has Been Signed on 06/07/2022 11:42 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ELEVATIONSFACILITY NUMBER:
197690036
ADMINISTRATOR:JORDAN ARONOFFFACILITY TYPE:
772
ADDRESS:3836 KANAN ROADTELEPHONE:
(858) 695-4069
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY: 6CENSUS: 5DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Blake Forbes - Operations ManagerTIME COMPLETED:
12:00 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) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with Operations Manager Blake Forbes  and explained the reason for the visit. This facility is licensed as a Social Rehabilitation Facility, Short Term Crisis Residential Treatment Program with a maximum capacity of 6 ambulatory adults. There are (5) clients in care at this time. Between 9:30am - 12pm, LPA toured physical plant with Forbes and the following was observed:

The kitchen appeared to be clean at this time and the appliances and fixtures functional during the time of visit.  LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects were observed stored in a locked closet outside of the kitchen. Extra supply of perishable and non-perishable foods were observed stored in the garage as well. LPA observed emergency food supplies to be properly stored in the garage. No Cleaning supplies and toxins were observed in the kitchen at this time. Fire extinguishers were observed to be fully charged and scheduled for service later this month. At approximately 10am, LPA observed clients participating in a group activity in kitchen dining table.
There were six (6) bedrooms designated for client use, all furnished for single occupancy. Four (4) of the bedrooms are located on the second story and two (2) on the ground floor. All bedrooms contained all required furnishings and bed linens.
There were six and one half (6 1/2) bathrooms for resident use. All bathrooms had fixtures that appeared clean and functional and contained all required supplies.  The hot water was measured in each bathroom between 105 - 120 degrees Fahrenheit.
COMMON AREAS: These included the dining area, an adjacent living room, as well as two other living rooms and a group therapy room. There were sufficient furnishings to accommodate a maximum capacity of 6 clients.
LAUNDRY ROOM: There is a laundry room with washer & dryer and cabinets with locks to store laundry and cleaning supplies and keep inaccessible.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/07/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATIONS
FACILITY NUMBER: 197690036
VISIT DATE: 06/07/2022
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
26
27
28
29
30
31
32
Continued from 809

MEDICATION ROOM: There is a medication room located across from group therapy room. LPA observed door to be locked and a medication cabinet inside equipped were observed equipped with locks.

STAFF OFFICE: The Tech Office is located adjacent to the Laundry Room and is capable of being secured and inaccessible to clients except with appropriate supervision. The first aid kit is located in the office. LPA observed a sufficient supply of PPE properly stored.

SURROUNDING GROUNDS: There are extensive grounds that include a tennis/basketball court, in-ground swimming pool, covered deck, lawns and garden areas. The pool is equipped with a net covering that keeps the pool inaccessible when not in use. There were sufficient furnishings appropriate for outdoor use and shaded areas. The front yard contains a large fountain that has been emptied of water. There is a clinical office next to the tennis court area used for one one one meetings with clients.

The LPA spoke with  Blake Forbes regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate the each bedroom as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted, report issued and sent via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2