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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801597
Report Date: 10/26/2023
Date Signed: 10/26/2023 04:05:42 PM


Document Has Been Signed on 10/26/2023 04:05 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:A LOVING HEART SENIOR CAREFACILITY NUMBER:
565801597
ADMINISTRATOR:DIORENA ROCK/ MICHEAL V.FACILITY TYPE:
740
ADDRESS:28 WALES STREETTELEPHONE:
(805) 230-3818
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
10/26/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:40 PM
MET WITH:Diorena "Rocky" RockTIME COMPLETED:
04:15 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 12:40 p.m. The LPA was greeted by the Administrator Diorena Rock and informed them of the reason for the visit.

The LPA and the 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.

BEDROOMS/BATHROOMS: Beginning at 1:00 p.m. the LPA inspected the bedroom and bathroom areas. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six designated client rooms and one staff room. Medications are located in a locked cabinet in the kitchen. The three client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. At 1:04 p.m. the LPA observed accessible clorox wipes in resident room #1. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured at 110.4 degrees Fahrenheit in the hallway bathroom.

KITCHEN: The LPA toured the kitchen/food service area. Knives and additional cleaning supplies are stored inaccesible and locked in the garage. At, 1:38 p.m. the LPA observed unlocked refrigerated medications in the kitchen refrigerator. At 1:46 p.m. the LPA observed a variety of expired foods ranging from canned sliced mangoes expired 1/20/23, expired vegetables, expired mayonnaise dated 5/3/23, expired imitation crab dated 9/9/23, expired sour cream dated 10/9/23, expired teriyaki sauce dated 12/11/22, moldy Brie and Swiss cheese, expired phyloo dough dated 3/6/21, expired prosciutto dated 9/16/23, expired pickles dated 9/29/22, expired roast pork dated 6/14/23, expired milk dated 10/8/23 and 10/23/23, expired romaine lettuce and expired egg whites dated 8/16/22. Kitchen appliances were in operable condition. Despite the expired foods observed the facility had a sufficient supply of perishable and non-perishable food at the time of visit.

**Continued LIC 9099-C**

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
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 10/26/2023 04:05 PM - It Cannot Be Edited

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: A LOVING HEART SENIOR CARE
FACILITY NUMBER: 565801597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as multiple food items were observed to be expired ranging from milk, vegetables and canned goods which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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The Licensee agreed to the follwoing:
1. To dispose of all expired food items. Plan of correction met.
2. Conduct a full audit of all food items and provide proof to CCL no later than 11/3/2023.
Type A
Section Cited
CCR
87465(h)(2)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as refrigerated prescription medication was observed to be unlocked and accessible in the kitchen refrigerator which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Licensee agreed to the following:
1. Immediatley lock all accessible medications. Plan of correction met at the time of the visit.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 2 of 4


Document Has Been Signed on 10/26/2023 04:05 PM - It Cannot Be Edited

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: A LOVING HEART SENIOR CARE
FACILITY NUMBER: 565801597

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/26/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as cleaning supplies were abserved to be accessible in bathroom located in room #1 and under the kictchen sink which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/27/2023
Plan of Correction
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Licensee agreed to the following:
1. To immediatley lock any accessible cleaning supplies. Plan of correction met at the time of the visit.
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: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/26/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 3 of 4


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: A LOVING HEART SENIOR CARE
FACILITY NUMBER: 565801597
VISIT DATE: 10/26/2023
NARRATIVE
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COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 73 degrees. Smoke detector(s) and carbon monoxide detector were tested at 2:15 p.m. and operational at the time of the visit. There are two fire extinguishers which were fully charged and last serviced on February 16, 2023. The LPA did not observe all required postings as facility sketch, emergency disaster plan and resident rights were not posted however Administrator was in possession of the required postings and advised the they will put them up.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use that is single latched. There is a gated pool which is inaccessible to residents in care. Exits are free of obstructions. The garage is where the washer and dryer are held, including additional refrigerator with perishable food items. Emergency food and water are kept in the garage. Due to time constraints, the LPA will return at a later date to complete the inspection.

The LPA obtained the following documents:


- LIC500 Personnel Report
- LIC9020 Client Roster
- Liability Insurance


The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 10/26/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/26/2023
LIC809 (FAS) - (06/04)
Page: 4 of 4