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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609101
Report Date: 06/07/2022
Date Signed: 06/07/2022 02:13:11 PM


Document Has Been Signed on 06/07/2022 02:13 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:LADYFACE VIEW LIVING LLCFACILITY NUMBER:
197609101
ADMINISTRATOR:HORACIO LOPEZFACILITY TYPE:
740
ADDRESS:29322 DEEP SHADOW DRIVETELEPHONE:
(818) 532-7525
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:6CENSUS: 4DATE:
06/07/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:30 PM
MET WITH:Connie Roush - Administrator TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived to this facility today to conduct a One (1) year Required inspection of this facility with emphasis on infection control practices and procedures. LPA met with Back pu Administrator Connie Roush and explained the reason for the visit.

A tour of the physical plant was conducted with administrator approximately between 12:30pm - 2:30pm  LPA inspected facility for Fire Safety, Personal Accommodations and Services, and Food Service. The following was noted: Facility is a single story residence consists of five (5) resident bedrooms and four (4) bathrooms.  There is one (1) additional bedroom for staff use. LPA observed (2) fully charged fire extinguishers purchased in July of 2021. All smoke alarms and carbon monoxide detector were tested and functioned properly during time of visit.  LPA observed all required postings in the living area. The facility serves residents with dementia, the auditory alarms on the exit doors were tested and functioned properly at the time of visit.

Kitchen:  The kitchen appeared clean and the appliances and fixtures functional during the time of visit.  LPA observed a sufficient amount of perishable and non-perishable food at the facility; Sharp objects are stored in a locked cabinet  to the left of the dishwasher.

Bedrooms:  The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets.

Bathrooms:  LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. The hot water was measured in each bathroom during physical plant tour. Hot water measured within the required limit of 105-120 degrees Fahrenheit in all bathrooms during visit.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/07/2022
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 2


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: LADYFACE VIEW LIVING LLC
FACILITY NUMBER: 197609101
VISIT DATE: 06/07/2022
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Continued from 809

Common Areas:  These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

The LPA spoke with Connie Rosh regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate each bedroom as a single isolation room if the facility has a confirmed case of COVID-19. COVID-19 testing is conducted weekly if anyone shows any symptoms. The facility’s policies and procedures as it pertains to infection control are adequate at this time.

Exit interview conducted, report issued and sent via email.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 06/07/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/07/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2