197602743-3-14-2024-29-AS-MARO-D3CV4Z-20240314160709

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197602743
Report Date: 03/14/2024
Date Signed: 03/14/2024 04:07:48 PM

COMPREHENSIVE INSPECTION

Document Has Been Signed on 03/14/2024 04:07 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LEISURE LIVING		FACILITY NUMBER:	197602743
ADMINISTRATOR:	MICHELLE MAURER		FACILITY TYPE:	740
ADDRESS:	5608 ROCK CREEK RD.		TELEPHONE:	(818) 426-0099
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	6	CENSUS: 5	DATE:	03/14/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Michelle Maurer / Leah Dela Cruz		TIME COMPLETED:	04:10 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 11:00 a.m. The last annual conducted at this facility was on 02/16/2023. When the LPA arrived, there were four (4) staff and five (5) residents present. The LPA was greeted at the door by House Manager, Leah Dela Cruz and the reason for the visit was explained. The Administrator, Michelle Maurer arrived during the inspection. Entrance interview conducted.

At 11:07 a.m., the LPA along with the House Manager toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA inspected the kitchen/food service area at 11:17 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The knives and sharps were observed in a locked cabinet inaccessible.

COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 11:26 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed to be in compliance with a purchase date of 09/21/2023. The LPA observed a closet in the hallway with extra towels and linens.

Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE LIVING	FACILITY NUMBER: 197602743
	VISIT DATE: 03/14/2024

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Continued from LIC 809...
Hygiene items were observed locked and inaccessible in a hallway closet. The LPA observed required postings throughout the common space. There is a working telephone on premises. Working auditory alarms were observed in all doors at the time of the visit.

GARAGE: The garage was observed locked and inaccessible to clients at the time of the visit. The washer and dryer were observed inside the garage. Cleaning supplies and detergents were observed locked and inaccessible at the time of the visit. The facility has a sufficient amount of emergency food and water which was observed to be in good condition. The LPA observed a sufficient supply of Personal Protection Equipment (PPE).

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There was one (1) gate that self-latches. No bodies of water were noted at the time of the visit.

BEDROOMS: There are three (3) resident bedrooms which are double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are two (2) resident restrooms. The first restroom is located inside bedroom #1, and the second bathroom is located by the main hallway. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with hand liquid soap and paper towels; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms; the first bathroom measured 110.4 degrees Fahrenheit at 11:10 a.m.; and the second bathroom measured 111.0 degrees Fahrenheit at 11:12 a.m.

RECORDS: Records review began at 11:33 a.m.; five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order.

Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEISURE LIVING	FACILITY NUMBER: 197602743
	VISIT DATE: 03/14/2024

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Continued from LIC 809C...

Five (5) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were complete.

The last emergency disaster drill took place on 02/15/2024.

MEDICATIONS: Medications review began at approximately 2:00 p.m.; medications are centrally stored in a locked closet in the hallway. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRNs have physicians order on file. Medications are properly documented on the centrally stored medications and destruction record.

No citations issued. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2024

LIC809 (FAS) - (06/04)

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