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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610161
Report Date: 09/30/2021
Date Signed: 09/30/2021 12:11:25 PM

Document Has Been Signed on 09/30/2021 12:11 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:BETD SAN FERNANDO CARE LLCFACILITY NUMBER:
197610161
ADMINISTRATOR:TIKU, ELIZABETH A.FACILITY TYPE:
740
ADDRESS:628 NORTH LAZARD STREETTELEPHONE:
(818) 493-8351
CITY:SAN FERNANDOSTATE: CAZIP CODE:
91340
CAPACITY: 9CENSUS: 0DATE:
09/30/2021
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elizabeth TikuTIME COMPLETED:
12:20 PM
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Licensing Program Analysts (LPAs) Tuesday Cabiness and Nicholas Reed conducted a PRE-LICENSING visit to the above address 628 N. Lazard Street, CA 91340. LPAs met with Administrator/Licensee Elizabeth Tiku. The inspection included, physical plant, fire safety, personal accommodations, building and grounds, furniture/equipment, food service, supplies, records, administration, activities, and other related inspection areas, such as front and back yard. Fire Inspection was approved on July 29, 2021 which met fire department requirements for (4) rooms to be non-ambulatory, and room # 3, for bedridden only. Each room has smoke detectors, and three rooms have exit doors. Licensing requirement posting were not all visible, facility must post emergency disaster plan, complaint procedures, personal rights, emergency exit plan, and COVID signs. LPAs discussed with Administrator, the mitigation procedures and plan that need to implemented: such as COVID signs, visitor book, and handwashing station, and temperature checks at the front entrance.

The physical plant was toured inside and out with Administrator Elizabeth. The facility is a one level home, with (5) bedrooms, and (3) bathrooms; with (1) room for staff, and the remaining (4) for residents, with (2) shared and (2) private rooms. Food supply was inspected and observed, and storage areas, cabinets, pantries, cupboards, counters, and refrigerator were clean and appropriate for food preparation. There is a refrigerator stored in the garage filled with frozen meat and other food items. Knives and medication were stored in cabinets located in the kitchen area. Appliances were clean and functional, and utensils, plates, and cups were in good repair. Cleaning supplies, poisons, toxins, and chemicals were locked and stored in the garage and kitchen area. There was enough supply of linens and towels. Hygiene products were also available and located in storage area. LPA observed cleaning solutions, paper towels and PPE supplies.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Tuesday Cabiness
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: BETD SAN FERNANDO CARE LLC
FACILITY NUMBER: 197610161
VISIT DATE: 09/30/2021
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The common areas included the dining, living, bathroom, and bedrooms. LPAs, observed room # 5, without a mattress. Administrator will purchase this week. Doors and passageways were clear and unobstructed. Walls, ceilings, floors, window screens and all other rooms were clean, in good repair, and appropriately furnished. Resident rooms observed to have a mattress with pad, sheets, pillow, bedspread, dresser, closet space, and chair. Bathrooms were clean had functional fixtures, with soap and towels, grab bars and handwashing signs were posted. The water temperature measured at 106.3 degrees Fahrenheit. The back yard has (1) exit door that leads to the front yard. LPAs observed a fenced area, only to be used for residents, with the remaining area not to be used, that included a storage unit. Two gates and the water heater door need to be locked and secured. There are no swimming pools or other bodies of water, no visible hazards around the surrounding grounds. Backyard also had comfortable furnishings for resident’s use.

Smoke detectors were hard wired and carbon monoxide are operating correctly. Fire extinguisher is fully charged. Internet and telephone installation was completed. First aid kit inspected. Garage area was locked and secured, with laundry area, household supplies, and emergency food and water. Staff and client files will be stored locked cabinet, located in the garage area. Administrator informed LPAs, that a dementia and hospice waiver was submitted for approval. During today’s inspection, LPA did not have documents to support the approval. Administrator must contact the applications unit regarding both waivers. And there needs a correction for the capacity to be changed from 9 to 6.

The following procedures need to be in place, for license to cleared. Administrator

1. Mattress for room # 5

2. Facility must post emergency disaster plan, complaint procedures, personal rights, emergency exit plan, and COVID signs, visitor book, handwashing station, and thermometer at the front entrance.

3. Two gates and the water heater door in the backyard need to be locked and secured.

Exit interview, and COMP III conducted. Report issued to Administrator.

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

DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/30/2021
LIC809 (FAS) - (06/04)
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