565850400-1-18-2024-29-AS-ECAS-CZJSWR-20240116131446

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850400
Report Date: 01/16/2024
Date Signed: 01/18/2024 11:33:15 AM

Document Has Been Signed on 01/18/2024 11:33 AM - It Cannot Be Edited

Document is an Amendment of Original Document on 01/18/2024 09:32 AM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

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On 01/18/2024, Licensing Program Analyst (LPA) Elsie Campos issued an amended Pre-licensing report with corrective information pertaining to the approved fire clearance. LPA spoke to the Licensee via telephone and explained the reason for the call. Licensee was not available to meet at the facility and the report was provided electronically for signature.

On 1/16/2024, Licensing Program Analyst (LPA) Elsie Campos arrived at the facility announced at 10:15 a.m. to conduct a pre-licensing inspection. The LPA met with Licensee Amaliya Santiago and Applicant/Administrator Smbat Avetyan. This is a new facility application for (6) six residents’. Fire clearance was granted on 08/24/2023 for two (2) non-ambulatory residents in bedroom #1, one (1) non-ambulatory and one (1) bedridden resident in bedroom #2, one (1) ambulatory resident in bedroom #3 and one (1) ambulatory resident in bedroom # 4. Bedroom #5 is cleared as a staff room only. Component III was completed with the LPA during today’s visit and is RCFE administrator certified.

At 10:45 p.m., the LPA toured the physical plant areas inside and outside with applicants to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen knives are stored locked and inaccessible in a kitchen cabinet on the right-hand side of the kitchen stove. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were new, clean and functional. There is an adequate supply of emergency food and water located in the garage.

BEDROOMS: There are five (5) bedrooms in the facility; two (2) private bedrooms for resident use, two (2) shared bedrooms for resident use and one (1) staff room. The staff room is kept locked. The two (2) shared resident rooms have direct access to the outside. Lighting in the rooms was adequate. All resident rooms and staff room were set up with beds, night stands, lamps, chests of drawers, chairs and closet space. All doors have functioning audible devices.

Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: BALANCED LIVING BOARD AND CARE	FACILITY NUMBER: 565850400
	VISIT DATE: 01/16/2024

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BATHROOMS: There are three (3) full bathrooms for resident use; the bathroom located in the main hallway is designated for guests, staff and residents. All showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in all bathrooms. Hot water temperature in bathrooms measured between 115.0 – 118.5 degrees Fahrenheit.COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and activities available in the living room area for resident use. The facility smoke alarm system is hard wired; the smoke detectors were tested at 12:20 p.m. and operable at the time of the visit. There are two (2) fire extinguishers which were fully charged and last purchased on 7/21/2023. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted along the entrance wall. Other required postings are also posted along the entrance wall. However, the Ombudsman poster was missing, and the Administrator made arrangements to pick one up. MEDICATIONS: Medications will be stored in a locked cabinet in the kitchen to the left upon entry. The first aid supplies were complete, including a first aid manual, and will be stored in the medication cabinet. FILES: Resident and staff records will be stored in a filing cabinet in the living room to the right of the screened fireplace. LAUNDRY: The laundry area is located in the locked attached garage. Laundry detergent and chemicals are stored inaccessible in the locked garage. EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water noted on the premises.The back and sides of the house are separated from the front yard by gates at the north and south side passageways. The attached garage is used for additional storage space and emergency food supply. There are no other structures on the property. INFECTION CONTROL: The facility has an area that will be used as a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized

Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 01/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/16/2024

LIC809 (FAS) - (06/04)

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