195850435-4-11-2024-29-AS-ECOZ-D48V4B-20240411160603

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850435
Report Date: 04/11/2024
Date Signed: 04/11/2024 04:06:53 PM

Document Has Been Signed on 04/11/2024 04:06 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	TRUE LIVING CARE LLC		FACILITY NUMBER:	195850435
ADMINISTRATOR:	HAVSGAARD, CHRISTIAN		FACILITY TYPE:	740
ADDRESS:	22740 HATTERAS STREET		TELEPHONE:	(951) 580-7888
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 5	DATE:	04/11/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:15 AM
MET WITH:	Christian Havsgaard		TIME COMPLETED:	04:15 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	Licensing Program Analyst (LPA) Esther Cortez arrived at the facility announced at 10:15 a.m. to conduct a pre-licensing inspection. The LPA met with Applicant Representatives Christian Havsgaard and Vanessa Havsgaard. This is a change of ownership application from Bentley Hills (#195850277) to True Living Care LLC (195850435). The current capacity is for six (6) residents, the facility currently has five (5) residents. A dementia program was included in the plan of operation. The fire clearance was granted on 01/26/2024, for five (5) non ambulatory and one (1) bedridden. All bedrooms cleared for bedridden but only one (1) at any time. Applicant successfully completed Component III during today’s inspection. The LPA toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen knives are stored inaccessible in a drawer and cleaning supplies are locked in the cabinet under the kitchen sink. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food. BEDROOMS: There are six bedrooms in the facility all for resident use. The facility has one staff bedroom that is being used by staff as a private living quarter. The staff room is accessed through an attached staff bathroom. All rooms have direct access to the outside. Lighting in the rooms appeared adequate. Resident room #1, #2, #3, #4 and #6 were set up with beds, night stands, lamps, chests of drawers, chairs, and closet space. Resident bedroom #5 was not set up with a bed. Resident bedroom #5 is currently not occupied. Report will continue on LIC809-C (2ND PAGE).

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRUE LIVING CARE LLC	FACILITY NUMBER: 195850435
	VISIT DATE: 04/11/2024

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

BATHROOMS: There are five (5) full bathrooms. There are two (2) private bathrooms for resident use that are attached to resident bedrooms #1 and #2; there are (2) full bathrooms in the hallway that are designated for residents, staff, and guests. There is one (1) full bathroom for staff. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature measured in bathrooms measured between 99.0 – 123.1 degrees Fahrenheit. Applicant attempted to regulate water temperatures during visit.

COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and a cabinet with games and activities for resident use. The facility smoke alarm system is hard wired; the smoke detectors were operable at the time of the visit. The fire extinguisher was fully charged and last serviced 06/15/2023. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted in the facility hallway. Emergency telephone numbers are posted in the facility hallway. Other required postings are posted in the hallway and upon entry into the facility.

MEDICATIONS: Medications are in a medication room in the kitchen which is locked and inaccessible to residents in care. The first aid supplies were complete.

FILES: Resident and staff records are stored in the medication room in the kitchen which is locked and inaccessible to residents in care. LPA observed an unlocked filing cabinet with past resident documents in the entertainment area located at the back of facility. Files were locked away during todays visit.

LAUNDRY: There's a laundry room in the kitchen which is locked and inaccessible to residents in care.

GROUNDS: The facility has a covered car port. The LPA observed a variety of equipment underneath the covered car port which included two (2) mattresses, a stove, boxes, a disassembled hospital bed and other items. The LPA observed two Hoyer lifts outside the exterior passageways of exit #5. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water on the premises at the time of the visit.The LPA observed a locked storage unit in the back yard containing additional supplies and yard equipment

Report will continue on LIC809-C (3rd PAGE).

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: TRUE LIVING CARE LLC	FACILITY NUMBER: 195850435
	VISIT DATE: 04/11/2024

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

INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of PPE and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Facility is not compliance with Title 22 Regulations at this time. Applicant will be required to complete the following corrections and submit documentation to LPA Esther Cortez within 10 days:

- Documentation of water temperatures meeting Title 22 regulations
- Photo of cleared items in the carport.

Upon receipt of the above items, physical plant will be in compliance with Title 22 regulations. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2024

LIC809 (FAS) - (06/04)

Page: 3 of 3