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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609317
Report Date: 03/28/2024
Date Signed: 03/28/2024 02:02:13 PM

Document Has Been Signed on 03/28/2024 02:02 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 N.ASC, 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:
03/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Zhanna DavtianTIME COMPLETED:
02:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Sandra Urena arrived unannounced to conduct an annual inspection- continuation visit. The LPA was greeted by staff. The LPA informed them of the reason for the visit. Staff contacted the Administrator on the phone and stated that they would arrive shortly thereafter.

LPA Urena resumed the inspection by conducting additional physical plant inspection.

RECORDS: Records review began at 10:50 a.m., Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:30 p.m.; medications are centrally stored and locked in a cabinet in the garage/office area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection 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 LPA reviewed pertinent documents to the annual inspection.



No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 03/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 03/28/2024
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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