197609101-6-12-2023-29-AS-ECOZ-CSQW2T-20230612165451

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609101
Report Date: 06/12/2023
Date Signed: 06/12/2023 04:57:00 PM

Document Has Been Signed on 06/12/2023 04:57 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LADYFACE VIEW LIVING LLC		FACILITY NUMBER:	197609101
ADMINISTRATOR:	HORACIO LOPEZ		FACILITY TYPE:	740
ADDRESS:	29322 DEEP SHADOW DRIVE		TELEPHONE:	(818) 532-7525
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	6	CENSUS:	DATE:	06/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:37 AM
MET WITH:	Ann-Hazel Lopez- Administrator		TIME COMPLETED:	05:00 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 (LPA’s) Esther Cortez arrived at the facility unannounced to conduct a required annual visit at 11:37 a.m.When the LPA arrived, there was two staff and four clients present. The LPA was greeted by Caregiver Ana Marie Leyva and informed them of the reason for the visit. Administrator Ann-Hazel Lopez shortly arrived. At 11:45am the LPA conducted a tour of the physical plant with caregiver Ana Marie Leyva. The following was noted: Facility is a single story residence that 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 October of 2022. 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. The 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 the communal bathroom during physical plant tour. Hot water measured 115.2 degrees Fahrenheit, within the required limit of 105-120 degrees Fahrenheit.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

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
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LADYFACE VIEW LIVING LLC	FACILITY NUMBER: 197609101
	VISIT DATE: 06/12/2023

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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. The facility maintained a
comfortable temperature of 77 degrees.

Garage: The garage is where the washer and dryer are held, including additional non-perishable emergency food items. Cleaning supplies and disinfectants are kept in locked cabinets in the garage.

Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. There are no bodies of water on the premises.

File review: A review of facility files was initiate at 1:11pm and the following was observed.
The LPA reviewed four (4) of four(4) Client Files. All documents reviewed appeared complete and current.
The LPA observed documentation of Infection Control, Disaster prevention and last fire drill (conducted on 5/3/2023).
The LPA obtained Client Roster, Staff Roster, and facility Sketch.

Interviews: At 2:53pm and 3:00pm the LPA conducted two (2) staff Interviews.

Due to time constraints the LPA will return to complete annual at a later date.Copy of Licensing Report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther Cortez	TELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:	DATE: 06/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/12/2023

LIC809 (FAS) - (06/04)

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