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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609101
Report Date: 08/24/2023
Date Signed: 08/24/2023 12:28:47 PM

Document Has Been Signed on 08/24/2023 12:28 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 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:
08/24/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
09:05 AM
MET WITH:Ann-Hazel Lopez- Administrator TIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Annual Continuation Visit to the facility to continue the annual inspection visit initiated on 06/12/2023. The LPA was greeted by Caregiver Angel Leyva and informed them of the reason for the visit. Administrator Ann-Hazel Lopez arrived shortly.

Today the LPA conducted interviews, staff files review, and medication audit.

Interviews: At 9:45 a.m. the LPA initiated interviews. The LPA conducted one (1) staff and two (2) resident Interviews. No immediate concerns voiced during the visit.

Record Review: At 10:00 a.m. a review of staff files was initiated. Five personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Record review revealed that three staff (S1, S2, S3) out of five did not have proof of the 4 hours of annual training for postural supports, restricted health conditions, and hospice care. Three staff (S1, S2, S3) are missing 4 hours out of 8 hours of annual dementia training.

Medication audit: Medications review began at 11:30 a.m.; 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.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D): Exit interview conducted and copy of the report and appeal rights provided to Administrator Ann-Hazel.
Desaree Perera
Esther Cortez
DATE: 08/24/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/24/2023
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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Document Has Been Signed on 08/24/2023 12:28 PM - It Cannot Be Edited


Created By: Esther Cortez On 08/24/2023 at 12:15 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LADYFACE VIEW LIVING LLC
FACILITY NUMBER: 197609101

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/24/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.625(b)(2)
Other Provisions
(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as three out of five staff did not have 4 hours of postural supports, restricted health conditions, and hospice care annual training, and were missing four out of eight hours of annual dementia training which poses a potential health and safety risk to persons in care.
POC Due Date: 08/31/2023
Plan of Correction
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The administrator agrees to have all staff complete the require annual training for dementia, postural supports, restricted health conditions, and hospice care. Proof will be submitted to CCL by 8/31/23.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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
LICENSING EVALUATOR NAME:Esther Cortez
LICENSING EVALUATOR SIGNATURE:
DATE: 08/24/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/24/2023


LIC809 (FAS) - (06/04)
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