197609488-8-15-2023-31-AS-ERIS-CUQQ37-20230815114817

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609488
Report Date: 08/15/2023
Date Signed: 08/15/2023 11:48:24 AM

Document Has Been Signed on 08/15/2023 11:48 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	LIVELY HOME CARE		FACILITY NUMBER:	197609488
ADMINISTRATOR:	TOPACIO, MARFIEBETH		FACILITY TYPE:	740
ADDRESS:	44328 LIVELY AVE		TELEPHONE:	(661) 945-5376
CITY:	LANCASTER	STATE: CA	ZIP CODE:	93536
CAPACITY:	6	CENSUS: 3	DATE:	08/15/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:25 AM
MET WITH:	Ariel Acorda / Staff		TIME COMPLETED:	12:00 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	On 08/15/2023 at 8:25 a.m. Licensing Program Analyst (LPA) Evelin Rios arrived at the facility listed above to conduct an unannounced annual inspection. LPA observed appropriate Covid-19 postings on the outside of the front door. LPA was greeted by Ariel Acorda and granted access. Ariel requested LPA sign in. LPA observed required postings along the entry wall of the facility. Staff #2 (S2) greeted LPA. Ariel called the Administrator Marfiebeth Topacio and notified Administrator LPA was at the facility. LPA explained the reason for the visit. Administrator could not meet LPA at the facility today due to a schedule appointment and designated staff Ariel Acorda to sign today's report. At 8:30 a.m. LPA toured the physical plant of the facility, and the following was observed: Kitchen/ Dinning area: Ariel was preparing breakfast for two (2) out of three (3) residents. One resident was already eating breakfast. Appliances and fixtures were functioning properly. LPA observed cleaning products kept locked in the laundry room by the kitchen. LPA observed knives locked in a kitchen drawer. LPA observed a sufficient amount of 2-day perishable and 7-day non-perishable food at the facility; properly stored. Dining area had appropriate table and chairs to sit the capacity of the facility. LPA observed one (1) of two (2) fire extinguisher fully charged by the kitchen with last serviced date of 03/23/2023 and a second fire extinguisher fully charged by a staff bedroom and one (1) resident's bedroom. Living room: The living room was clean and properly furnished. Fireplace not in use secured with a screen. LPA observed board games and books for residents use. Bedrooms: LPA inspected five (5) out of five (5) resident bedrooms. Two (2) bedrooms are currently vacant and bedrooms are for private use. LPA observed each client room to be properly furnished with one bed, appropriate night stand, chair, bedding and with sufficient lighting and storage. LPA observed extra linens in a hallway closet outside the bedrooms. (Continued on LIC809-C)

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

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
N LA & CEN COA AC/SC, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: LIVELY HOME CARE	FACILITY NUMBER: 197609488
	VISIT DATE: 08/15/2023

NARRATIVE

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(LIC809-C Continued)
Bathrooms: LPA observed the temperature of the house to be a comfortable 77 degrees with the a/c set at 74 degrees. The facility has 2 bathrooms. The LPA took water temperature from one (1) out two (2) bathrooms sink and temperature was 110.5 degrees F. LPA observed the bathrooms to be clean and properly supplied with shower mats, pull up bars, toilet paper, paper towels and trash bins with lids.

Laundry: Laundry room is kept locked. Washer and dryer were observed to be operational.

Surrounding Grounds: Entry and exits were free of obstruction. There is a covered patio with appropriate furniture for clients to use. LPA also observed a shed that was locked and used as storage.

At 9:30 a.m. LPA observed Ariel test a dual smoke and carbon monoxide detector. Detector is hardwired and interconnected to other detectors located through out the facility. Detectors were observed to be functioning properly.

Resident/Staff Records: At approximately 10:00 a.m. three (3) out three (3) client records and two (2) out of two (2) staff records were reviewed to insure compliance.

Medications: Centrally stored medications are maintained in a locked cabinet by staff bedroom. Medications were observed locked. Refills are either done automatically every 30 days, or ordered by the physician. Each resident has their own pharmacy. Centrally stored medication records were reviewed for proper documentation. Medication records are maintained manually. LPA and Ariel reviewed residents' medication.

At 11:00 a.m. LPA interviewed two (2) out of three (3) residents, resident #3 (R3) was sleeping while LPA was conducting interviews. LPA interviewed two (2) out of two (2) staff.

Pursuant to Title 22 Division 6 of the CA Code of Regulations, there were no deficiencies observed during todays visit. Exit interview conducted. A copy of the report Issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) 596-4373
LICENSING EVALUATOR NAME: Evelin Rios	TELEPHONE: 424-299-6104
LICENSING EVALUATOR SIGNATURE:	DATE: 08/15/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/15/2023

LIC809 (FAS) - (06/04)

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