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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609893
Report Date: 11/02/2021
Date Signed: 11/02/2021 03:15:09 PM

Document Has Been Signed on 11/02/2021 03:15 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:LAKEVIEW COMFORT LIVING INCFACILITY NUMBER:
197609893
ADMINISTRATOR:KESHISHIAN, TINAFACILITY TYPE:
740
ADDRESS:11406 KAMLOOPS STREETTELEPHONE:
(818) 590-8557
CITY:SYLMARSTATE: CAZIP CODE:
91342
CAPACITY: 6CENSUS: 5DATE:
11/02/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Tina KeshishianTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA) Tuesday Cabiness arrived at the facility to conduct an unannounced infection control inspection/visit. LPA was greeted by caregivers Fleming Nkonjera and Mombolwa, who allowed LPA to enter the facility. Upon entering the facility, there routine symptom screening in place at the front door. Everyone was informed the reason of the visit. Administrator Tina Keshishian was notified and arrived shortly after. Administrator reported to LPA, that there have not been any active or past COVID cases at the facility. There current census is (5), and staff and residents have been vaccinated. LPA observed Licensing COVID-19 posting inside the facility at the front door entrance, and throughout the facility.

The infection control inspection was conducted throughout the facility with the caregivers. The facility has (4) bedrooms; with (2) shared and (2) private rooms. Beds were kept (6) feet apart. All common areas were observed to be clean, including bathrooms, that had soap and towels. There were hand washing signs observed at the kitchen sink, bathrooms and resident rooms. LPA conducted a mitigation plan review with the Administrator, to obtain information how the facility has implemented the plan. According to the latest documentation of the facility's mitigation plan, it was reported that the Administrator submitted an incomplete report. Administrator reported to LPA that the plan was submitted to previous LPA Gary Tan. LPA requested a copy and the Administrator emailed to LPA during the visit. LPA reviewed the report and requested some additional information. Administrator will correct and submit to LPA. The facility is not currently conducting COVID-19 surveillance testing; but will begin to implement a plan for staff. Daily temperature for residents and staff are performed daily. Visitation is conducted outside on the backyard patio. Residents eat together and practice social distancing at the dining room table. Administrator informed LPA, she received the PINs from the department, and conducts training to staff in relation to COVID-19.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/02/2021
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., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: LAKEVIEW COMFORT LIVING INC
FACILITY NUMBER: 197609893
VISIT DATE: 11/02/2021
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There are designated rooms for potential positive COVID residents. PPE, chemicals, cleaning supplies, and paper products were observed, with a viable supply.

The facility had sufficient staff and Administrator recently hired additional staff. The facility has not had any positive COVID-19 reports for staff or residents. Administrator informed LPA that they continue to implement the best practices for their facility; which has kept them COVID-19 free since the beginning of the pandemic.

The facility is aware to report any changes with residents or staff to Licensing pertaining to positive COVID-19 cases.

Exit interview and copy of report provided to Administrator.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE:

DATE: 11/02/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/02/2021
LIC809 (FAS) - (06/04)
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