197607861-2-26-2024-29-AS-VCOY-D2U39P-20240226170327

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607861
Report Date: 02/26/2024
Date Signed: 02/26/2024 05:03:36 PM

Document Has Been Signed on 02/26/2024 05:03 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:	DREAM HOME FOR SENIORS, LLC		FACILITY NUMBER:	197607861
ADMINISTRATOR:	ZENAIDA & RICARDO VELASCO		FACILITY TYPE:	740
ADDRESS:	20743 CLARK STREET		TELEPHONE:	(818) 667-4111
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY:	6	CENSUS: 0	DATE:	02/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:30 PM
MET WITH:	Zenaida Velasco		TIME COMPLETED:	05:15 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 Analysts (LPAs) Valeria Conway and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. The last annual visit was done on 12/21/2022. Administrator Zenaida Velasco opened the door at 2:45 PM. and explained the reason for the visit. Administrator reported to LPAs that the facility does not have any residents at this time, that her family is living at the residence. No residents present. LPAs toured the physical plant areas inside and outside, with Administrator at 2:55P.M. BEDROOMS: There are (4) four bedrooms designated for resident use. Bedroom #2 and Bedroom #4 have a direct exit to the exterior. Each bedroom has adequate lighting. Bedroom #3 leads to a hallway, which allows for access to Bedroom #5 and Bedroom #6; however, those two rooms designated for staff. There is an exterior door that leads to Bedroom #5 and Bedroom #6. Staff are aware that once they have residents in Bedroom #3, staff would need to enter their rooms through the exterior door. At 3:04P.M. room #1 had a locked door and Administrator was unable to open. Administrator stated she did not have a key to the room. RESTROOMS: There are (2) bathrooms designated for resident use. There is a bathroom designated for staff use only. Bathrooms are in operating condition with grab bars and non-skid surfaces. The LPAs advised the Administrators to ensure that bathrooms were stocked with paper towels and hand-washing signs prior to allowing resident admissions. Hot water temperature was tested throughout the home and was within normal ranges between 105.0 F and 120.0 F. Continued on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

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

FACILITY NAME: DREAM HOME FOR SENIORS, LLC	FACILITY NUMBER: 197607861
	VISIT DATE: 02/26/2024

NARRATIVE

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Continued from LIC 809

COMMON SPACES: At the time of the visit, common seating area and dining room furniture were

observed to be in good condition. The common spaces included the living room, dining area, activity room, entertainment room and office area. The LPAs observed cameras in all common spaces and exterior. The LPAs did not observe the required postings in the common hallway and Administrator was aware they are required to post posting throughout facility upon admission. Fire extinguishers were observed to be serviced and fully charged, last serviced on 03/27/2023. The backyard has a covered outdoor area equipped with furniture for resident use. There are no bodies of water noted.

KITCHEN: Appliances in the kitchen appeared functional. The supply of perishable and nonperishable food is adequate.

INTERVIEWS: No residents interviews as facility has no residents.

RECORDS: No residents file reviewed as facility has no residents.

One (1) personnel record was reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Facility does not have an Administrator file at the facility.

MEDICATION REVIEW: No medication reviewed as facility has no residents.

The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Administrator Zenaida Velasco refused to sign report at the time of the exit interview. A copy of the report was printed and issued to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/26/2024 05:03 PM - It Cannot Be Edited

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: DREAM HOME FOR SENIORS, LLC	FACILITY NUMBER: 197607861
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87755(a)

(a) Any duly authorized officer, employee or agent of the licensing agency may, upon proper identification and upon stating the purpose of his/her visit, enter and inspect the entire premise of any place providing services at any time, with or without advance notice. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on facility plant tour/LPAs observations, the licensee did not comply with the section cited above as bedroom #1 was locked and Administrator did not have key to open, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 03/01/2024
	Plan of Correction
1 2 3 4	The Administrator will review regulation 87755 and submit a statement of understanding to CCL before POC date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 02/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/26/2024

LIC809 (FAS) - (06/04)

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