197609890-2-16-2023-29-AS-KDUK-CP4T5Z-20230216132623

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609890
Report Date: 02/16/2023
Date Signed: 02/16/2023 01:26:52 PM

Document Has Been Signed on 02/16/2023 01:26 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:	LEISURE LIVING PROPERTIES		FACILITY NUMBER:	197609890
ADMINISTRATOR:	ANGEL ARABACA		FACILITY TYPE:	740
ADDRESS:	5965 CALMFIELD AVE		TELEPHONE:	(310) 991-2937
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY:	6	CENSUS: 5	DATE:	02/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Angel Arabaca		TIME COMPLETED:	01:35 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) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices and procedures. Upon arrival, LPA met with Administrator Angel Arabaca and explained the reason for the visit. Entrance interview conducted. At 12:34PM, LPA along with Administrator, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Bedrooms: There were seven (7) bedrooms total with one (1) bedroom designated for staff use and six (6) private resident bedrooms. LPA observed staff room to be locked at the time of the visit. All bedrooms for resident use were properly furnished and had appropriate bedding and linens. Bathrooms: There were two bathrooms designated for resident use. Both bathrooms appeared clean, properly supplied and had functional fixtures, including grab bars and non-skid shower surfaces. Water temperature was measured in the common hallway restroom at 12:39PM and measured at 110.5 degrees Fahrenheit, which is within the required range. Common Areas: These included the living rooms and dining areas. The common areas were properly furnished and all furnishings appeared to be clean and in good condition at the time of the visit. Surrounding Grounds: The garage is attached to the home. Emergency/disaster and PPE supplies are properly stored in the garage inaccessible to residents in care. The laundry area was located in the garage with cleaning supplies inaccessible to residents at this time. LPA observed a shaded seating area with Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

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 3

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: LEISURE LIVING PROPERTIES	FACILITY NUMBER: 197609890
	VISIT DATE: 02/16/2023

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
26
27
28
29
30
31
32

patio furniture appropriate for outdoor use and plenty of room for outdoor activities. LPA did not observe any obstructions to emergency exits at this time. Side gates are self latching and no bodies of water were noted during this visit.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable food stored in the fridge and non-perishable food properly stored in a pantry to the right of the fridge Knives and sharps are stored in a locked drawer to the right of the sink.

The carbon monoxide and smoke alarms were tested at 12:49PM and all functioned properly. The fire extinguisher appeared to be fully charged, but was last serviced on 12/03/2021. During today's visit, Administrator called to arrange service.

INFECTION CONTROL: During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and hand sanitization. LPA observed 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 a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/16/2023

LIC809 (FAS) - (06/04)

Page: 2 of 3