191220759-5-28-2024-31-AS-NRED-D5PUQ6-20240528154636

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191220759
Report Date: 05/28/2024
Date Signed: 05/28/2024 03:47:02 PM

Document Has Been Signed on 05/28/2024 03:47 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.ASC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	KIM'S LOVE & CARE		FACILITY NUMBER:	191220759
ADMINISTRATOR:	MASTERSON, KIMBERLY YVONNE		FACILITY TYPE:	740
ADDRESS:	24107 VICTORY BLVD		TELEPHONE:	(818) 340-2213
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY:	6	CENSUS: 3	DATE:	05/28/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:45 PM
MET WITH:	Aura Cortez		TIME COMPLETED:	03:50 PM

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At 1:30 p.m. on 05/28/2024, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with staff and disclosed the reason for the visit.

The facility was last visited on 05/12/2022 for an annual visit. It is a single story building with four (04) bedrooms, two (02) bathrooms, kitchen, common areas, pool, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents. Approved hospice waiver for 1.

LPA and staff toured the facility inside and out at 1:40 p.m.

The front gate was unlocked with an inward facing, self-closing latch. The front yard was well maintained. There was a shaded seating area under the front porch with furniture in good condition. A screening station at the front contained a visitor log, digital thermometer, sanitizing wipes, hand sanitizer, N95 masks, and test kits which were all locked. Walls, floors, ceilings, windows, and screens were clean and in good repair. At 1:50 p.m. LPA measured the room temperature to be 74 degrees Fahrenheit. Postings included Ombudsman contacts, confidential complaint contacts, facility license, administrator certificate, rights of resident councils, and resident rights.

The facility has four (04) bedrooms. Two (02) bedrooms are designated for staff. Both staff rooms were free of hazards and clean. Bedroom #3 is private and Bedroom #2 is shared. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. All emergency exits were unlocked and free of obstructions.

LPA observed an adequate supply of perishable and non-perishable food. All surfaces were clean. The stove hood was sanitary. Sharp objects were locked under a counter. Cleaning solutions were locked under the sink. Medications were locked above a pantry. At 2:00 p.m. LPA observed a fully charged fire extinguisher in the kitchen. It was purchased on 10/10/2023. Two (02) storage closets contained resident clothes and extra supplies.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

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

FACILITY NAME: KIM'S LOVE & CARE	FACILITY NUMBER: 191220759
	VISIT DATE: 05/28/2024

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A laundry area was located near the kitchen. LPA observed a washer and dryer in good condition. LPA also observed a first aid kit by the appliances.

All emergency exit paths were free from obstructions. Exit gates and doors were unlocked. At 2:10 p.m. LPA tested the carbon monoxide and smoke detector to be operational.

The back yard was well maintained. A storage shed was locked. The pool was fenced and the gate was locked in two (02) places with padlocks. A covered seating area was located by the pool. Furniture was in good condition.

The facility has two (02) bathrooms. All bathrooms contained liquid soap, paper towels, handwashing instruction signs, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. At 2:45 p.m. LPA measured the water temperature in the large bathroom to be 110.6 degrees Fahrenheit.

During today's inspection, the facility is in compliance with Title 22 regulations.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Naira Margaryan	TELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Nicholas Reed	TELEPHONE: (818) 669-8178
LICENSING EVALUATOR SIGNATURE:	DATE: 05/28/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/28/2024

LIC809 (FAS) - (06/04)

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