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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610458
Report Date: 10/19/2023
Date Signed: 10/19/2023 11:55:06 AM

Document Has Been Signed on 10/19/2023 11:55 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:ECLIPSE SENIOR CAREFACILITY NUMBER:
197610458
ADMINISTRATOR:DISHOYAN, NERSESFACILITY TYPE:
740
ADDRESS:7045 BECKFORD AVENUETELEPHONE:
(559) 907-8787
CITY:RESEDASTATE: CAZIP CODE:
91335
CAPACITY: 6CENSUS: 0DATE:
10/19/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Nerses DishoyanTIME COMPLETED:
12:00 PM
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At 9:00 am, Licensing Program Manager (LPM), Nichelle Gilyard, and Licensing Program Analysts (LPAs), Huma Rahimi and Leslie Ngo-Castaneda conducted an announced Pre-Licensing visit to the above facility and met with Administrator Nerses Dishoyan and Armine Dishoyan (facility designee). LPM and LPAs team conducted an entrance interview with the Administrator. At the time of this visit LPAs did not observed any residents present in the facility. Fire Clearance dated 08/04/2023 and received for five (5) Non-ambulatory and one (1) Bedridden (room #1) residents. In addition, approved Hospice waiver for six (6) residents was received on 08/29/2023. The purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with rules and regulations under California Code of Regulations, Title 22, Division 6. The facility is a single-story building. Today's site visit consisted of LPM and LPAs touring the physical plant inside and outside and observed the following:

KITCHEN: The facility has a Kitchen area that is equipped with a refrigerator, microwave oven, sink , and small refrigerator with a lock for medication. Stove was observed in a good working condition. LPAs observed adequate supplies of nonperishable food and dining ware to accommodate a maximum capacity of six (6). All knives and sharps are observed to be locked in a kitchen cabinet and inaccessible to residents. Administrator/Licensee was informed that the locking mechanism shall be maintained and inaccessible at all times. Fire Extinguisher was last purchased on 06/21/23, and was full.

BEDROOMS: There are four (4) bedrooms designated for residents use. Bedroom (1) is Bedridden and three (3) are Non-ambulatory. LPAs observed a model which was furnished with beds, dressers and required bedding and linen. The bedrooms have sufficient closet space and have sufficient lighting. Chest drawers were not observed, and the Administrator is going to soon purchase. Facility will have a no live-in staff at the facility. Bedroom # 4 is shared and the alarm is required.



Continue on LIC809-C
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE: DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/19/2023
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 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ECLIPSE SENIOR CARE
FACILITY NUMBER: 197610458
VISIT DATE: 10/19/2023
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BATHROOMS: At 9:35am LPAs and LMP observed all bathrooms are clean and in good repair. Properly supplied with toilet papers, soap and paper towels. LPAs observed Bathroom # 1 needs a grab bar and door alarm and the other bathroom was observed to have appropriate grab bar and a non-skid mat . The water temperature was noted at 130°. The Administrator is going to keep a log for five days of water temperature between 105°F to 120°F.

COMMON AREAS: LPAs observed all common areas to be clean in good repair. The facility maintains a comfortable temperature at 75°F. The living room and dinning rooms were properly furnished. No obstructions and or tripping hazards throughout the facility.

MEDICATION ROOM: The medication and facility staff/resident files will be kept in a locked cabinet located in the hallway adjacent to Room 4.

LAUNDRY ROOM: The laundry room is located outside in the garage behind the kitchen. LPM and LPAs observed a door with a lock. The washer/dryer appear to be in good condition. Laundry supplies are kept inaccessible when not in use with supervision.

SURROUNDING GROUNDS: The back of the facility has sufficient yard space. LPM and LPAs did not observe appropriate outdoor furniture, LPAs and LPM observe a covered shaded area for residents. The backyard is fenced. LPM and LPAs discussed the importance of maintaining the care and supervision to meet the needs of residents. There is a swimming pool that is fenced all around with a gate that will be kept locked at all times. The fence surrounding the swimming pool is approximately 5 feet high all around its parameters. You will need a key to unlock the padlock to gain entry to the swimming pool as it is kept locked at all times.

SMOKE DETECTORS/CARBON MONOXIDE. Smoke detectors and carbon monoxide were located throughout the facility. They were tested and observed to be operational.


Component III was conducted with the Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: ECLIPSE SENIOR CARE
FACILITY NUMBER: 197610458
VISIT DATE: 10/19/2023
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The licensee will need to complete the following:
1. Hot water temperature log for five (5) days.
2. Proof of chest drawer purchased
3. Photos of blinds for all rooms
4. Bathroom # 1 grab bar and alarm
5. Outdoor furniture, submit a photo

Please submit the above items within ten (10) days.

The facility is ready for operation upon completion of requested items in this report and final approval of the application.
The licensee/Administrator should notify the Licensing agency of the admission of their first client.

Exit interview was conducted and with a copy of this report was provided to the Applicant/Administrator.
SUPERVISORS NAME: Nichelle Gillyard
LICENSING EVALUATOR NAME: Huma Rahimi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023
LIC809 (FAS) - (06/04)
Page: 3 of 3