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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609317
Report Date: 02/24/2023
Date Signed: 02/24/2023 11:48:11 AM

Document Has Been Signed on 02/24/2023 11:48 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:BLUE HORIZONFACILITY NUMBER:
197609317
ADMINISTRATOR:DAVTIAN, ZHANNAFACILITY TYPE:
740
ADDRESS:11727 BLYTHE STREETTELEPHONE:
(818) 640-4703
CITY:NORTH HOLLYWOODSTATE: CAZIP CODE:
91605
CAPACITY: 6CENSUS: 4DATE:
02/24/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Zhanna DavtianTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices, and procedures. LPA Urena arrived at the facility at 10:10 a.m., met with the administrator Zhanna Davtian at 10:30 a.m., and explained the purpose of the visit.

At 10:30 a.m., LPA Urena and Administrator conducted a tour from 10:30 a.m. to 11:15 a.m. of the inside and outside of the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The facility is a one-story dwelling located in the front of the property.

Infection Control: Upon entry, the facility has a sign in book, and sanitizing gel. Infection Control signage was visible at entrance. Temperature was taken and recorded.

Common Areas: The common areas (living room and dining room), walls and flooring were checked for cleanliness and were observed to be in good condition. Furniture was observed to be clean, appropriate, and in good condition. Fire extinguishers were observed to be serviced within the last year.

Kitchen: Knives are stored in a locked box which is stored in the kitchen cupboard. Kitchen appliances were in operable condition. The facility has enough supply of perishable and a seven-day supply of non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Prepared foods were safely covered with lids.

Continues on LIC 809C...

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/24/2023
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: BLUE HORIZON
FACILITY NUMBER: 197609317
VISIT DATE: 02/24/2023
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Garage Area: An adequate supply of emergency food and water supply for six residents and two staff were observed. Diapers, and Personal Protection Equipment (PPE) is adequate, and the facility is able to obtain additional supplies as needed. Medications were observed to be locked away in the office/garage are, and inaccessible to residents.

Bedrooms: Bedrooms were furnished appropriately with appropriate furnishings, bed linens, and sufficient lighting. The facility has three bedrooms, which have double occupancy.

Bathrooms: The residents’ bathroom was observed to be clean; shower area was in clean condition with grab bars and a non-skid mat available. Paper towels were available for drying hands. Hand washing sign was displayed, and sufficient amounts of soap and paper products in each restroom.

Outdoor Space: Backyard has a shaded outdoor area equipped with outdoor furniture in good repair for residents’ use. There were no bodies of water noted.



INFECTION CONTROL: During today’s visit, the LPA spoke with the Supervisor regarding the facility’s
infection control practices. Upon entry, the facility has a point for symptom screening. The LPA observed an
adequate supply of Personal Protective 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. The facility’s policies and procedures as
it pertains to infection control is adequate.

No deficiencies were cited at this time. Exit interview was conducted, the report was reviewed with the Administrator and a copy of the report was provided via email. Signatures were obtained.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 02/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2023
LIC809 (FAS) - (06/04)
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