197609932-2-2-2023-29-AS-BBAI-CNNUM3-20230202144140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609932
Report Date: 02/02/2023
Date Signed: 02/02/2023 02:41:49 PM

Document Has Been Signed on 02/02/2023 02:41 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	KAREN'S SENIORS CARE HOME, INC.		FACILITY NUMBER:	197609932
ADMINISTRATOR:	ZINKOFSKY, BRANDON		FACILITY TYPE:	740
ADDRESS:	17610 HAYNES STREET		TELEPHONE:	(818) 205-3820
CITY:	VAN NUYS	STATE: CA	ZIP CODE:	91406
CAPACITY: 6		CENSUS: 6	DATE:	02/02/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Brandon Zinkofsky - Administrator		TIME COMPLETED:	02:40 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual. This annual had a specific emphasis on infection control practices and procedures. Upon arrival LPA met with Administrator Brandon Zinkofsky and explained the reason for the visit. At approximately 12:30pm, LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was fully charged and last serviced in Jan 16, 2023. Kitchen: LPA observed Kitchen to be inaccessible to residents at this time. The kitchen appeared to be clean and the appliances and fixtures functional. Properly labeled medications and sharp objects were observed to be locked in a cabinet to the right of the fridge. LPA observed a sufficient amount of perishable food stored in the fridge and non-perishable food properly stored in a pantry inside of the laundry room on the exterior of the kitchen. Laundry area located between living room and kitchen. LPA observed this room to be inaccessible to residents at this time. Cleaning supplies and detergents were observed locked in a cabinet below the water tank. Bedrooms: There were (7) bedrooms total with (1) bedroom designated for staff use, which was located next to the kitchen. LPA observed staff room to be empty at this time. All bedrooms for clients use were properly furnished and had appropriate bedding and linens. At approximately 12:40pm, LPA observed (4) residents sleeping in their bedrooms. Bathrooms: There were (3) bathrooms designated for clients' use. All bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was measured between 111 - 114 degrees Fahrenheit.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

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: KAREN'S SENIORS CARE HOME, INC.	FACILITY NUMBER: 197609932
	VISIT DATE: 02/02/2023

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Common Areas: These included the living rooms and dining areas. The common areas were properly furnished and appeared to be relatively clean at this time. There is a hallways closet observed to be inaccessible to residents at this time. LPA observed PPE, jackets and other supplies for facility use at this time. At approximately 12:45pm, LPA observed resident watching television in the living room. Hallway closets by bedroom #1 and living room were observed to store extra linen and toiletries.

Surrounding Grounds: LPA observed shaded patio furniture appropriate for outdoor use and plenty of room for outdoor activities. LPA did not observe any obstructions to emergency exits at this time. There is a detached garage located on the property. LPA observed garage to be used for storage of unused furniture, medical supplies and decorations. Facility is surrounded by a metal gate. LPA observed the gated doors nearest front entry and the larger gate on driveway to both be single action locks.

INFECTION CONTROL: During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed 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 facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted and report issued to the Administrator.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:	DATE: 02/02/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2023

LIC809 (FAS) - (06/04)

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