<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610675
Report Date: 11/04/2024
Date Signed: 11/04/2024 12:25:28 PM

Document Has Been Signed on 11/04/2024 12:25 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:BREATH OF SUNSHINE PLUSFACILITY NUMBER:
197610675
ADMINISTRATOR/
DIRECTOR:		SIMONIAN, RUZANNAFACILITY TYPE:
740
ADDRESS:17546 CANTARA STREETTELEPHONE:
(323) 610-5587
CITY:NORTHRIDGESTATE: CAZIP CODE:
91325
CAPACITY: 6CENSUS: 0DATE:
11/04/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:45 AM
MET WITH:Ruzanna SimonianTIME VISIT/
INSPECTION COMPLETED:
12:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 11/4/24, at 09:45am, Licensing Program Analysts (LPAs) Angelica Segovia and Gina Saucedo conducted an announced Pre-licensing visit. LPA's met with Administrator Ruzanna Simonian at 9:45 am.

An application was submitted to Community Care Licensing Division-CCLD on 07/15/2024, Initial license for a Residential Care Facility for the Elderly (RCFE), 60 years and older. The requested capacity is for six (6) non-ambulatory and one (1) may be bedridden, total of up to six (6) residents and fire clearance was approved on 8/20/2024-Room number three (3) is for bedridden.

Structure: The facility is a single-story building with four (4) bedrooms and two (2) bathrooms.

Entrance: There is only one (1) entrance being utilized. Required postings such as: Personal Rights of Residents, Rights of Resident by Council, Family Council, Infection Control, Emergency and Disaster Plan, Facility Sketch, Theft and Loss Policy, House Rules, Non-discrimination Policy and YES are posted along hallway leading to bedrooms.

Toxins, cleaning solutions, and laundry detergents are kept locked under the sink in the kitchen inaccessible to residents.

Living/Dining area: The living room is neat, clean, and organized with sufficient seating for both residents and staff. The dining area is also neat, clean, and organized. Both rooms are properly furnished and in good repair. The facility maintains a comfortable temperature of seventy (70) degrees. No firearms observed or will be maintained on the premises.

Resident/staff files: Resident and staff files will be kept locked in filing cabinet in office through the passageway hallways inaccessible to residents.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE: DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/04/2024
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: BREATH OF SUNSHINE PLUS
FACILITY NUMBER: 197610675
VISIT DATE: 11/04/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Kitchen: Sufficient supplies of dishes, cups, and silverware located within the kitchen cabinets and drawers. Sharps are stored on the left side of the kitchen locked and inaccessible to the residents. Sufficient supply of food such as: canned goods, bottles of water, cereal were observed in the garage. Kitchen appliances are working and are in good repair. First-aid kit observed as well. There is a working telephone on the premises.

Emergency: Fire extinguisher located in the kitchen on the right side and dated 7/20/2024.

Medications: Medication will be stored both in a kitchen cabinet and filing cabinet in the office. Daily medication will be kept in kitchen cabinet locked. Monthly medication will be stored in filing cabinet within the office. Medication storage is equipped with a lock to ensure medications will not be accessible to clients.

Bedrooms: The bedrooms are properly furnished with bed, nightstand, applicable lightening, and seating. Window coverings are in good repair, not broken or damaged.

Bathroom: The bathrooms are in proper condition and will be equipped with sufficient personal hygiene for each client. Towels and washcloths will not be shared.

Hallways: Hallway is properly lighted. Extra linens/covers observed in storage cabinet within the passageway.

Staff room: there is no designated staff room in the facility.

Water Temperature: The water temperature was measured in the bathrooms at 118.8 Fahrenheit and is within regulations.

LIC809C-continued

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
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: BREATH OF SUNSHINE PLUS
FACILITY NUMBER: 197610675
VISIT DATE: 11/04/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Smoke detectors: Dual interconnected smoke detectors and carbon monoxide observed to be working properly and were tested.

Garage: The garage is located outside separate from the facility and is currently being utilized for storage, emergency food, and Laundry. Dryer and washer observed to be in good repair. The garage has a half bathroom for staff use only.

Outside: The outside is clean, free of hazards, and will be properly furnished with sufficient seating. A shaded area for residents was observed as well.



Pool: no bodies of water located at the facility.

Administration: The facility had submitted an Emergency and Disaster Plan For Residential Care Facilities For The Elderly and Infection plan.

The Component III Orientation RCFE was shown/reviewed with the Administrator.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted and copy of this report issued to the administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Gina Saucedo
LICENSING EVALUATOR SIGNATURE:

DATE: 11/04/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/04/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3