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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197610350
Report Date: 02/20/2025
Date Signed: 02/20/2025 12:55:44 PM

Document Has Been Signed on 02/20/2025 12:55 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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:PURE HEART CARE LIVINGFACILITY NUMBER:
197610350
ADMINISTRATOR/
DIRECTOR:		DELA CRUZ, CHRYSEL S.FACILITY TYPE:
740
ADDRESS:45731 TRAFALGAR DRIVETELEPHONE:
(661) 579-9637
CITY:LANCASTERSTATE: CAZIP CODE:
93534
CAPACITY: 6CENSUS: 3DATE:
02/20/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Chrysel Dela CruzTIME VISIT/
INSPECTION COMPLETED:
01:30 PM
NARRATIVE
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On 2/20/2025 at approximately 10:00 AM, Licensing Program Analysts (LPAs), Angelica Segovia and Leslie Ngo-Castaneda conducted an unannounced annual visit to the facility. LPAs were greeted by Administrator Chrysel Dela Cruz. LPAs stated the reason for their visit.

LPAs asked for census, Staff/Resident Roster, and Insurance. LPAs conducted a physical plant tour at approximately 11:00 AM and the following was noted:

There is only one entrance being utilized at the facility. The facility is a single unit building with four (4) bedrooms and two (2) bathrooms currently occupying three (3) residents. There is one (1) designated staff room. The facility has approved fire clearance for six (6) non-ambulatory residents. Hospice waiver approved for three (3). Screening area is located immediately upon entrance. Sign in sheet, hand sanitizer, gloves and masks are available. Required postings such as See/Say Something, Facility Sketch, and Facility License are located immediately upon entrance.

Common areas: Living room and dining room observed to be neat, clean, and organized. Both rooms observed to be properly furnished and in good repair. The facility maintains a comfortable temperature at 73°F. Fire extinguisher located in the kitchen and dated 04/24/24. Fireplace: Observed to be covered and inaccessible to residents. Working telephone observed.

Kitchen: Kitchen observed to be clean and inaccessible to pests. Sufficient supplies of seven (7) day nonperishable food and two (2) day perishable foods were observed. Knives and sharps observed to be locked in kitchen drawer. Toxins and cleaning solutions locked underneath kitchen sink. Kitchen appliances observed to be working and in proper condition. (continued on LIC 809-C)
SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE: DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/20/2025
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 S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: PURE HEART CARE LIVING
FACILITY NUMBER: 197610350
VISIT DATE: 02/20/2025
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Bedrooms: The Residents' rooms are adequately furnished with appropriate furniture and lighting system. Hallways/passageways are lighted appropriately. Extra linens/covers stored in storage closet located in hallway’s passageway.

Bathrooms: Bathrooms were checked for cleanliness and proper operation. Appropriate grab rails and skid mats were observed and in proper condition. The hot water temperature was measured within regulations at 114.3°F.

Laundry Room: The laundry room is located near the bedrooms and kept locked. Laundry appliances observed to be working and in proper condition. Additional cleaning solutions, toxins, and laundry detergent stored in locked storage cabinet in hallway leading towards laundry room. Garage: The garage can be accessed from inside the facility and is kept locked. Extra refrigerator and freezer stocked with additional food for residents

Backyard: The backyard of the facility is equipped with a designated shaded area with outdoor furniture for residents. There is no body of water in this facility.

Medications: Medication logs and facility files kept stored in locked cabinet in the kitchen. First-aid kit observed to be equipped with but not limited to bandages, scissors, digital thermometer, tweezer, and manual.

Smoke detectors and carbon monoxide observed to be working properly and were tested. Last Fire Drill conducted on 1/22/25.

Resident/Staff Records: LPAs conducted a complete file review of resident records. Resident records appeared to be complete and updated. Staff records: LPAs conducted a complete file review of staff records. Staff records appeared to be complete and updated.

Citation issued. See LIC 809D. There were no other immediate health and safety hazard observed during the day of inspection. Exit interview conducted, Appeal Rights given, and a copy of this report was provided to the Administrator.

SUPERVISORS NAME: Troy Agard
LICENSING EVALUATOR NAME: Angelica Segovia
LICENSING EVALUATOR SIGNATURE:

DATE: 02/20/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/20/2025 12:55 PM - It Cannot Be Edited


Created By: Angelica Segovia On 02/20/2025 at 12:14 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: PURE HEART CARE LIVING
FACILITY NUMBER: 197610350

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/20/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(h)(4)
87465 (h) The following requirements shall apply to medications which are centrally stored: (4) All centrally stored medications shall be labeled and maintained in compliance with state and federal laws...

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in (1) out of (1) Resident's medication was mismanaged in bubble pack which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 02/21/2025
Plan of Correction
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Administrator will send vendor training on medication to LPA Segovia.
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:Troy Agard
LICENSING EVALUATOR NAME:Angelica Segovia
LICENSING EVALUATOR SIGNATURE:
DATE: 02/20/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/20/2025


LIC809 (FAS) - (06/04)
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