197608616-6-10-2024-31-AS-LNCA-D64UZN-20240610160146

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197608616
Report Date: 06/10/2024
Date Signed: 06/10/2024 04:03:11 PM

Document Has Been Signed on 06/10/2024 04:03 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:	BLUE RIDGE HOME CARE #2		FACILITY NUMBER:	197608616
ADMINISTRATOR/ DIRECTOR:	KARLA PLATA		FACILITY TYPE:	735
ADDRESS:	16040 DEARBORN STREET		TELEPHONE:	(818) 892-1582
CITY:	NORTH HILLS	STATE: CA	ZIP CODE:	91343
CAPACITY: 6		CENSUS: 6	DATE:	06/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:18 AM
MET WITH:	Karla Plata- Administrator		TIME VISIT/ INSPECTION COMPLETED:	12:45 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, Amelia Biley and explained the reason for the visit. Approximately, around 9:45 AM administrator Karla Plata arrived and was explained for the reason of the visit. At 10:00 AM, with the assistance of administrator, 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 5/6/2024. During the visit the facility is at 71 degrees Fahrenheit. The facility is fire cleared for six (06) non-ambulatory of which one (01) may be bedridden. 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 cabinet in the kitchen. Office space is in the living room. Medications of the residents properly labeled medications were locked in the cabinets in the office station. Bedrooms: There were five (5) bedrooms designated for residents' and staff use. Three (3) of the that bedrooms are in use by residents were properly furnished with appropriate dresser, beddings, and linens with sufficient lighting. Room #1, room #2, and room #3 are properly furnished and are shared. There are two (2) staff bedroom in the facility, one of the staff bedroom is located in the hallway beside resident room #1 and another staff bedroom is located beside resident bedroom #2, staff bedrooms are locked with no medication in sight. Continue to LIC 809-C

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

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: BLUE RIDGE HOME CARE #2	FACILITY NUMBER: 197608616
	VISIT DATE: 06/10/2024

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Bathrooms: There are three (3) bathrooms designated for residents' and staff use. Bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured at 111.4 degrees Fahrenheit for bathroom #1 located in the hallway beside room #3. Bathroom #2 measured 109.4 degrees Fahrenheit located beside bedroom #2. Bathroom #3 is for staff use only located inside staff room. Cleaning supplies are being stored in a locked cabinet in the laundry room. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

Common Areas: These included the living room and dining area for residents. The common areas were properly furnished. Fireplace is close, non-operational and blocked. 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). Office is located beside the living room.

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 inside the garage that are kept secured. The facility does not have a swimming pool or body of water. The garage is attached and is used for storage and incontinence for residents and staff refrigerator.

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.

SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Leslie Ngo-Castaneda
LICENSING EVALUATOR SIGNATURE:	DATE: 06/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024

LIC809 (FAS) - (06/04)

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