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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608615
Report Date: 01/07/2022
Date Signed: 01/07/2022 01:57:34 PM

Document Has Been Signed on 01/07/2022 01:57 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:BLUE RIDGE HOME CAREFACILITY NUMBER:
197608615
ADMINISTRATOR:KARLA B. PLATAFACILITY TYPE:
740
ADDRESS:16604 LASSEN STREETTELEPHONE:
(818) 892-2184
CITY:NORTHRIDGESTATE: CAZIP CODE:
91343
CAPACITY: 6CENSUS: 5DATE:
01/07/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Karla PlataTIME COMPLETED:
02:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz conducted an unannounced visit on this day in response to an incident report submitted to the Woodland Hills Regional Office by the facility administrator.

It was reported that on 12/11/21 Resident 1 (R1) ingested a small amount of hand sanitizer that was located at the front entrance of the facility for visitors to use. R1 was taken to the hospital as a precaution and discharged the same day with no changes in medication or adverse effects noted.

Report reviewed, signed and delivered. Exit interview conducted, deficiency cited on 809D page.
SUPERVISORS NAME: Eva Miller
LICENSING EVALUATOR NAME: Alexander Pitz
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2022
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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Document Has Been Signed on 01/07/2022 01:57 PM - It Cannot Be Edited


Created By: Alexander Pitz On 01/07/2022 at 01:45 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BLUE RIDGE HOME CARE
FACILITY NUMBER: 197608615

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 01/07/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
01/07/2022
Section Cited
CCR
80087(g)

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80087(g) Disinfectants, cleaning solutions, poisons, firearms and other items that could pose a danger if readily available to clients shall be stored where inaccessible to clients.

This requirement is not met as evidenced by:
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Administrator has relocated the hand sanitizer so that it is no longer a danger to residents in care. Deficiency cleared on site.
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Based on the incident report submitted to licensing, the facility did not ensure that R1 was unable to access the bottle of hand sanitizer, which poses a potential risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Eva Miller
LICENSING EVALUATOR NAME:Alexander Pitz
LICENSING EVALUATOR SIGNATURE:
DATE: 01/07/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 01/07/2022


LIC809 (FAS) - (06/04)
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