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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610293
Report Date: 04/06/2023
Date Signed: 04/06/2023 01:20:34 PM

Document Has Been Signed on 04/06/2023 01:20 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:SUNRISE AT LINDLEY IFACILITY NUMBER:
197610293
ADMINISTRATOR:MELIKSETYAN, LUSINEFACILITY TYPE:
740
ADDRESS:9955 LINDLEY AVETELEPHONE:
(747) 218-9141
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 2DATE:
04/06/2023
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:LUSINE MELIKSETYAN, ADMINISTRATOR TIME COMPLETED:
11:00 AM
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LPAs arrived at 10:00am and was greeted by caregiver Tamara. Upon entering the caregiver had to slide a cardboard box away from the door in order to let the LPAs enter the home. When asked why the box was blocking the exit door, the caregiver stated so that one resident would not leave the facility. LPA Spaeth informed her she cannot block the exit door. LPAs informed the Administrator of the purpose of the visit.

A tour of the physical plant was conducted with Administrator about 10:30 am. The facility has six (6) bedrooms and three (3) bathrooms currently occupying two (2) residents. LPAs spoke to both residents and they seem happy with the facility.

LPAs observed rooms to have the appropriate bedding. There is a night stand and sufficient lighting for each resident. LPAs tested the exit doors auditory system, and it was observed to be operational for each room. At 10:45 am LPAs observed all bathrooms to have non-skid mats, grab bars, and the appropriated wash your hands signs posted. LPAs observed no chemicals/hazardous items in the laundry area. LPAs conducted a tour of the kitchen around 10:38 and observed there to be sufficient food. Frozen foods are properly wrapped and stored appropriately. Food storage and preparation areas care clean and inaccessible to pests. LPAs observed a lighter located in an unlocked draw. The Administrator immediately locked it away. All knives and sharp object were locked and inaccessible to residents in care. LPAs toured the outside area of the facility at 10:45 am. LPA observed appropriate outdoor furniture, with a covered shaded area for residents. No bodies of water on the premises. LPAs observed the living room to be neat and clean along with the dining room. The facility maintains a comfortable temperature. The medication cabinet was locked and inaccessible to residents in care.

An exit interview conducted, deficiencies issued per CA Code of Regulations, Title 22, and a copy of this report was given to the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Shira Stamps
LICENSING EVALUATOR SIGNATURE: DATE: 04/06/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/06/2023
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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Document Has Been Signed on 04/06/2023 01:20 PM - It Cannot Be Edited


Created By: Shira Stamps On 04/06/2023 at 12:05 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE AT LINDLEY I
FACILITY NUMBER: 197610293

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 04/06/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
04/07/2023
Section Cited
CCR
87307(d)(6)

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87307 Personal Accomodations &Services(d) The following space and safety provisions shall apply to all facilities: (6) All outdoor and indoor passageways and stairways shall be kept free of obstruction.

This requirement was not met as evidicence by:
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LPAs observed the caregiver remove the box. LPAs discussed with the Administrator and caregiver that the exit door cannot be blocked. The Licensee will conduct an in-service training for all staff on the cited section by the POC due date and provide LPA with signatures of all staff that have completed the training.
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Based on LPA's observation staff did not comply with the section cited above in that staff blocked the exit door with a long heavy cardboard box which poses an immediate health, safety or personal rights risk to persons in care.
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Type A
04/07/2023
Section Cited
CCR87705(f)(1)

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87705 Care of Persons with Dementia
(f)The following shall be stored inaccessible to residents with dementia: (1)Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement was not met as evidence by:
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The Licensee will conduct an in-service training for all staff on the cited section by the POC due date and provide LPA with signatures of all staff that have completed the training. The lighter was locked away during today's visit.
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Based on observation the Licensee did not comply with the section cited above in that a lighter was found in an unlocked draw in the kitchen, which poses an immediate health, safety, or personal rights risks to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Nichelle Gillyard
LICENSING EVALUATOR NAME:Shira Stamps
LICENSING EVALUATOR SIGNATURE:
DATE: 04/06/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/06/2023


LIC809 (FAS) - (06/04)
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