197604456-4-11-2023-31-AS-MCAA-CQSSRT-20230411140651

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197604456
Report Date: 04/11/2023
Date Signed: 04/11/2023 02:06:56 PM

Document Has Been Signed on 04/11/2023 02:06 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
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A LOVING HEART SENIOR CARE		FACILITY NUMBER:	197604456
ADMINISTRATOR:	ROCK, DIORENA		FACILITY TYPE:	740
ADDRESS:	10541 DEBRA AVE.		TELEPHONE:	(818) 363-2560
CITY:	GRANADA HILLS	STATE: CA	ZIP CODE:	91344
CAPACITY:	6	CENSUS: 6	DATE:	04/11/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:59 AM
MET WITH:	Gloria Avila		TIME COMPLETED:	02:20 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) Michael Cava conducted an Annual Required visit and inspection of the facility. LPA met with staff, Gloria Avila and explained the reason for the visit. Administrator, Diorena Rock could not attend the annual for the day due to an emergency. House Manager, Michael Vicente came in her place. At approximately 11:15am, with the assistance of staff, LPA took a tour of the physical plant. Required postings were observed in the entry area. The smoke alarms are interconnected and battery operated. There is a carbon monoxide detector that functions properly installed in the hallway between resident rooms. The fire extinguisher is located in the kitchen. The charge date is February 17, 2023. Kitchen: The kitchen appliances and fixtures were functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives were stored in a locked drawer in the kitchen. Properly labeled medications were locked in one of the kitchen cabinets. Bedrooms: There were five (5) bedrooms designated for residents' use. Four (4) bedrooms are designated for private use, and one (1) room is shared. All five bedrooms, in use by residents were were properly furnished with appropriate beddings and linens with sufficient lighting. Bathrooms: There are two (2) bathrooms designated for residents' use. Both bathrooms were properly supplied and had functional fixtures. Hot water temperature was measured from the bathroom sink at 108 degrees Fahrenheit. No cleaning supplies or hazardous items were present in each bathrooms during the inspection. Common Areas: These included the living room and dining area. The common areas were properly furnished. The auditory alarms on all exit doors were on and functional at the time of the visit.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

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

FACILITY NAME: A LOVING HEART SENIOR CARE	FACILITY NUMBER: 197604456
	VISIT DATE: 04/11/2023

NARRATIVE

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Surrounding Grounds: Entry/exits were free of obstruction. There was furniture appropriate for outdoor
use. The outdoor area was free of hazards. There is a swimming pool that is fenced all around it's parameters. The fence was at least five foot high with a gate, that is also five foot high. Gate was observed locked, making it inaccessible to residents to enter. The laundry area is located in the garage, which is inaccessible to residents.

Resident Files: LPA conducted a file review of resident records to insure compliance of licensing forms.

Staff Files: LPA also conducted a file review of staff records to insure forms and training are up to date and compliance with licensing forms.

Medications: Medication and Medication Records were review for proper documentation.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during the visit. Exit Interview Conducted and a Copy of the Report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Michael Cava	TELEPHONE: (818) 389-7921
LICENSING EVALUATOR SIGNATURE:	DATE: 04/11/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2023

LIC809 (FAS) - (06/04)

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