197609055-9-5-2024-31-AS-NRED-D8TRXU-20240905132521

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609055
Report Date: 09/05/2024
Date Signed: 09/05/2024 01:25:38 PM

Document Has Been Signed on 09/05/2024 01:25 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SK MARATHON HOME CARE		FACILITY NUMBER:	197609055
ADMINISTRATOR/ DIRECTOR:	KIM, SUN IL		FACILITY TYPE:	740
ADDRESS:	7246 FALLBROOK AVE		TELEPHONE:	(818) 912-6757
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY: 6		CENSUS: 4	DATE:	09/05/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Sarah Kim		TIME VISIT/ INSPECTION COMPLETED:	01:25 PM

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At 9:00 a.m. on 09/05/24, Licensing Program Analysts (LPAs) Nicholas Reed and Angelica Segovia conducted an unannounced annual inspection. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

The facility was last visited on 06/10/24 for a complaint visit. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, common areas, and outdoor areas. It has an approved fire clearance for five nonambulatory (05) residents, of which one (01) may be bedridden in Bedroom #2. The facility serves residents with dementia. Approved hospice waivers for two (02).

At the main entrance, LPAs observed a maintained front yard with a shaded seating area. LPAs observed postings for confidential complaint contacts, emergency contacts, ombudsman contacts, personal rights, rights of resident councils, emergency disaster plan, facility sketch with evacuation routes labeled, administrator certificate, and facility license.

Walls, floors, windows, screens, and blinds were clean and in good repair. At 9:20 a.m. LPAs measured the room temperature to be 80 degrees Fahrenheit. The living room contained furniture in good repair, an appropriately covered fireplace, games, puzzles, reading material, music, and television. The hallway closet contained additional hygiene supplies. A camera was used to monitor the living area.

The facility has four (04) bedrooms. One (01) bedroom is designated as a staff room. The staff room was locked and free of hazards. All bedrooms contained a chair, appropriate lighting, nightstand, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. Bedroom #1 and Bedroom #2 had one (01) bed with full bed rails. The residents’ files contained the appropriate prescriptions for full bed rails. Beds with wheels were in the locked position.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SK MARATHON HOME CARE	FACILITY NUMBER: 197609055
	VISIT DATE: 09/05/2024

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All emergency exit paths were free from obstructions. Exit gates were unlocked with self-closing latches. Two (02) out of two (02) auditory alarms were turned on and functioning. At approximately 9:30 a.m., smoke and carbon monoxide detectors were tested and operational. At approximately 9:35 a.m. LPAs observed a fully charged fire extinguisher in the kitchen. It was last purchased on 09/07/23.

The facility has two (02) bathrooms. All bathrooms contained liquid soap, paper towels, trash can with a tight fitting lid, grab bars near the toilet and shower, and a non-skid mat in the shower. At approximately 9:40 a.m. LPAs determined the water temperature to be within regulations.

LPA observed an adequate supply of perishable and non-perishable foods. The stove hood was clean. Appliances were in good condition. Sharps were locked above the countertop. Cleaning solutions were locked next to the sharps. Medications were locked in a separate cabinet in the dining area.

A washing machine and dryer were located outside of the kitchen. Both were in working order. Detergents were locked above the appliances.

LPAs observed a shaded patio area in the front of the facility. The patio contained furniture in good condition. Ramps leading out were free of tripping hazards and had secure hand rails. The back yard contained fruit-bearing trees and exercise equipment. At 9:50 a.m., LPAs called the house telephone which was deemed operational.

During today's inspection, the facility was in compliance with Title 22 regulations. No immediate health and safety risks were observed.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 09/05/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/05/2024

LIC809 (FAS) - (06/04)

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