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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197690045
Report Date: 08/23/2022
Date Signed: 08/23/2022 10:54:27 AM

Document Has Been Signed on 08/23/2022 10:54 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:ELEVATION BEHAVIORAL HEALTHFACILITY NUMBER:
197690045
ADMINISTRATOR:BLAKE FORBESFACILITY TYPE:
772
ADDRESS:3855 BRUNSTON COURTTELEPHONE:
(818) 877-0934
CITY:WESTLAKE VILLAGESTATE: CAZIP CODE:
91362
CAPACITY: 6CENSUS: 5DATE:
08/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Blake ForbesTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility unannounced to conduct a required annual/legal-non compliance visit at 9:30 a.m. This annual had an emphasis on infection control practices and procedures. The LPA met with Administrator Blake Forbes and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: There has been an ongoing issue with the facility's dishwasher; however there is another dishwasher on site in operable condition. The facility has repaired and attempted to replace the dishwasher on several occasions. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The client bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Restrooms are clean, sanitary and in operating condition. The common bathroom was observed with appropriate signs and stocked with paper towels. Signs promoting good hand hygiene were observed. Water temperature measured at 118.2 F.

COMMON SPACES: The LPA observed the living room, dining room, Great Room, laundry facilities and Gym on the first floor; and the library and movie theater on the second floor. At the time of the visit, furniture, walls, and flooring were observed to be in good condition. Fireplaces are inaccessible. Throughout today’s visit, the LPA observed appropriate signs in common areas that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. There is sanitizer available throughout the facility. At 10:15 a.m., the smoke detectors and carbon monoxide detectors were tested and were operable.

The backyard has a covered outdoor area equipped with furniture for client use. The in-ground pool and hot tub are appropriately fenced and locked. The garage is attached to the facility and locked. The detached pool house is designated for therapeutic services and is inaccessible to clients unless supervised by staff.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/23/2022
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. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ELEVATION BEHAVIORAL HEALTH
FACILITY NUMBER: 197690045
VISIT DATE: 08/23/2022
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FILES: During today's visit, the LPA reviewed client files. All files were in order.

INFECTION CONTROL: 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 a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted every Wednesday for those that are unvaccinated. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 08/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/23/2022
LIC809 (FAS) - (06/04)
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