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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610161
Report Date: 10/19/2024
Date Signed: 10/19/2024 02:05:41 PM

Document Has Been Signed on 10/19/2024 02:05 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/
DIRECTOR:		TIKU, ELIZABETH A.FACILITY TYPE:
740
ADDRESS:628 NORTH LAZARD STREETTELEPHONE:
(818) 493-8351
CITY:SAN FERNANDOSTATE: CAZIP CODE:
91340
CAPACITY: 6CENSUS: 4DATE:
10/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Elizabeth TikuTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Abeye Duguma met with Elizabeth Tiku for a Required One (01) Year visit. LPA explained the reason for the visit. A tour of the physical plant was conducted at around 9:00 AM and the following was noted:

There is one (01) entrance being utilized at the facility. The facility has a total of five (05) bedrooms, of which one (01) bedroom is for staff, and three (03) bathrooms. The facility is fire cleared for one (01) ambulatory, five (05) non-ambulatory of which one (01) may be bedridden in room #3 and a hospice waiver for six (06). The facility is currently occupying four (04) residents.

The facility has outdoor furniture with a covered shaded area for residents and visitors. The facility does not have a swimming pool/body of water. Laundry detergents, cleaning agents and other toxins are locked away.

Kitchen is sufficiently stocked with at least two (02) days perishable and seven (07) days non-perishable food. Frozen foods are wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests. Knives and sharps are observed to be locked and inaccessible to residents.

The living and dining room are neat and clean. The facility maintains a comfortable temperature at 73°F. The smoke and carbon monoxide detectors are hardwired, interconnected and observed to be operational. Fire extinguisher is located near the kitchen and observed to be fully charged.

(continued on LIC 809-C)

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2024
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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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: 10/19/2024
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The residents' rooms are adequately furnished with appropriate lighting system. Hallways are well lit. Residents have enough personal hygiene product provided by the licensee. The bathroom was checked for cleanliness and proper operations. The hot water temperature was measured at 116.9°F. Towels and washcloths are not shared. There was enough clean linen available in the cabinets.

LPA observed medication to be locked and inaccessible to residents. Facility maintains a complete first aid kit.

No health and safety hazards noted during the visit.

Exit interview conducted. Copy of this report issued.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Abeye Duguma
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2024
LIC809 (FAS) - (06/04)
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