197609101-6-15-2024-29-AS-VCOY-D69UK8-20240615153841

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609101
Report Date: 06/15/2024
Date Signed: 06/15/2024 03:39:41 PM

Document Has Been Signed on 06/15/2024 03:39 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:	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: 4	DATE:	06/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	ANn-Hazel Lopez		TIME COMPLETED:	03:50 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) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. When the LPA arrived, there was one staff and four clients present. The LPA was greeted by Caregiver Ana Marie Leyva and informed the reason for the visit. Caregiver contacted the Administrator by phone, Ann-Hazel Lopez, and subsequently transferred the call the LPA. During the call the administrator informed the LPA that she would arrive at the facility in a few hours due to personal reasons. At 1:50 pm Administrator arrived at the facility. At 12:20 p.m. 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. 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. At 12:30 p.m. hot water measured at 115.2 degrees Fahrenheit. Bedrooms: All resident’s bedrooms were properly furnished with at least one chair, a bed, night stand, chests of drawers, and sufficient lighting for each residents. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. The bedrooms were large enough to allow for easy passage between the beds and furniture. In addition, no bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair. Continued on LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

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: LADYFACE VIEW LIVING LLC	FACILITY NUMBER: 197609101
	VISIT DATE: 06/15/2024

NARRATIVE

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Continued from LIC809

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. Between 12:23 pm and 12:42 pm hot water was measured in all four (4). All bathrooms were within the required limit of 105-120 degrees Fahrenheit.

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 75 degrees. The LPA observed the required postings in the entry way and common sitting area. Combination smoke alarms and carbon monoxide detectors were tested at 10:10 am and were operational at this time. LPA observed (2) fully charged fire extinguishers purchased on 01/28/2024. LPA observed cameras in common areas.

Garage: The garage is where the washer and dryer are held, including additional non-perishable emergency food items and emergency water. Cleaning supplies and disinfectants are kept in locked cabinets in the garage all cleaning compounds were stored in areas separately from food supplies.

Surrounding Grounds (Outdoors): The front yard is free of obstructions, the two side gates have a self-latching door. There is a yard area in the front of the house. LPA also observed a patio in the back yard which had shade and seating areas and proper furniture for residents to enjoy. There were no bodies of water noted.

File review: A review of facility files was initiate at 11:23 pm and the following was observed. LPA reviewed four (4) of four (4) residents files and five (5) staff file including the administrator’s. All documents reviewed appeared complete and current. Additionally, LPA observed documentation of Infection Control, Disaster prevention and last fire drill conducted on 06/09/2024. LPA obtained Client Roster, Staff Roster, and facility Liability Insurance.

Continued from LIC809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

LIC809 (FAS) - (06/04)

Page: 2 of 3

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: LADYFACE VIEW LIVING LLC	FACILITY NUMBER: 197609101
	VISIT DATE: 06/15/2024

NARRATIVE

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Continued from LIC 809-C

OFFICE AREA: There is an office area with a computer for residents and staff to use. Above the computer desk, there is a cabinet where all resident’s medications are kept. LPA observed a complete 1st Aid Kit inside such cabinet. Medication audit: Medications review began at 10:37am; medications are centrally stored and locked in a cabinet in the living area; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Interviews: Between 9:45 am and 10:30 am the LPA conducted two (2) staff and three (3) residents’ interviews.

No deficiencies cited at this time. Exit interview conducted. Report issued and provided to Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 06/15/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/15/2024

LIC809 (FAS) - (06/04)

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