197610470-10-25-2023-31-AS-NRED-CWXPXS-20231025114250

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610470
Report Date: 10/25/2023
Date Signed: 10/25/2023 11:58:40 AM

Document Has Been Signed on 10/25/2023 11:58 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	BIG HEARTS RESIDENTIAL LIVING		FACILITY NUMBER:	197610470
ADMINISTRATOR:	BOTE, ELAINE P.		FACILITY TYPE:	740
ADDRESS:	22901 CANTLAY ST		TELEPHONE:	(818) 914-4254
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY: 6		CENSUS: 3	DATE:	10/25/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Elaine Bote		TIME COMPLETED:	12:00 PM

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At 10:00 a.m. on 10/25/2023, Licensing Program Analyst (LPA) Nicholas Reed conducted a prelicensing inspection. LPA met with the applicant and disclosed the reason for the visit. LPA and the applicant toured the facility inside and out at 10:15 a.m. today. No immediate health or safety hazards were noted during the time of this visit.

Today’s prelicensing visit is conducted due to a Change of Ownership with residents in care. It is a single story building with 6 bedrooms, 2 bathrooms, kitchen, garage, common areas, and outdoor areas. It has an approved fire clearance for 6 residents, of which 5 may be nonambulatory and 1 bedridden in Bedroom #5. The facility serves residents with dementia.

LPA observed a maintained front yard. The walkway leading to the main entrance was free of debris. Gardeners were observed sweeping and cleaning. Facility policies were observed at the main entrance. Additional postings located inside included but were not limited to an administrator’s certificate, personal rights, rights of resident councils, emergency disaster plan, facility sketch with evacuation routes clearly labeled, confidential complaint poster, Ombudsman contact poster, and facility menu.

The facility has 6 bedrooms. 1 bedroom is designated as a staff room. The staff room was unlocked but free of hazards. Of the 5 resident bedrooms, all bedrooms contained a chair, lamp, nightstand, dresser, storage, and a bed with adequate bedding. All furnishings were clean and in good condition. 3 residents were observed laying down. Bedroom #5 had a notice posted: “No smoking – Oxygen in use”.

The facility has 2 bathrooms. The bathroom designated for residents contained liquid soap, paper towels, grab bars and a non-skid mat in the shower, and a commode with grab bars. At approximately 10:30 a.m. LPA measured the water temperature in the resident bathroom to be 11.9.8 degrees Fahrenheit.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

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
WOODLAND HILLS S.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: BIG HEARTS RESIDENTIAL LIVING	FACILITY NUMBER: 197610470
	VISIT DATE: 10/25/2023

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Walls, floors, windows, screens, and blinds were clean and in good repair. At 10:40 a.m. LPA measured the room temperature to be 75.0 degrees Fahrenheit. Hallways contained functioning night lights.

LPA observed an adequate supply of perishable and non-perishable foods stored in the refrigerator, freezer, and pantry. The stove hood was clean. Appliances were in good condition. Sharps were locked below the countertop. Cleaning solutions were locked below the sink. Staff members carried the keys.

A washing machine and dryer were located in the garage. Both were in working order. Detergents were locked in a storage shed. The garage stored additional supplies.

LPA observed a covered patio area in the rear of the facility. The patio contained furniture in good condition. A storage shed was locked and contained additional supplies. A gardened area contained fruit bearing trees and plants. Perimeter fences were at least five (05) feet in height.

All emergency exit paths were free from obstructions. Exit gates were unlocked. Three (03) out of three (03) auditory alarms were turned on and functioning. Medications, staff files, and resident files were locked and inaccessible in the activity room. A complete first aid kit was also locked in the activity room. At 10:45 a.m. LPA called the house phone near the dining room, and it was confirmed to be functional. At approximately 10:50 a.m., smoke and carbon monoxide detectors were tested and operational. At approximately 11:00 a.m. LPA observed a fully charged fire extinguisher in the kitchen. It was last inspected on 04/21/2023.

LPA reviewed three (03) out of three (03) resident files at 11:05 a.m. Resident files were complete and up to date.

The facility vehicle was inspected at 11:20 a.m. and was in working order.

Component III was conducted with the applicant at 11:45 a.m.

During today's inspection, the facility was in compliance with Title 22 regulations. Pre-Licensing is complete and this facility has no deficiencies.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Naira Margaryan
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 10/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/25/2023

LIC809 (FAS) - (06/04)

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