565802407-5-19-2023-29-AS-MARO-CRYTJD-20230519144610

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802407
Report Date: 05/19/2023
Date Signed: 05/19/2023 02:47:02 PM

Document Has Been Signed on 05/19/2023 02:47 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:	LOVE CIRCLE HOME CARE LLC		FACILITY NUMBER:	565802407
ADMINISTRATOR:	TRAN, APRIL		FACILITY TYPE:	740
ADDRESS:	1936 EDGEWOOD DRIVE		TELEPHONE:	(805) 527-2378
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 5		CENSUS: 1	DATE:	05/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	April Tran		TIME COMPLETED:	03:00 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. The last annual conducted at this facility was on 06/22/2022. Upon arrival, there was one staff and one resident present. The LPA was greeted by staff and the reason for the visit was explained. The Administrator arrive shortly after. Entrance interview conducted.

At 9:30 a.m. the LPA 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.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 9:35 a.m. Knives are kept locked under the kitchen sink. Cleaning supplies and disinfectants are kept locked under the sink inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 9:37 a.m., the hot water temperature was measured in the kitchen at 128.6 degrees Fahrenheit.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene. The facility has 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 infectious disease case. The facility’s policies and procedures as it pertains to infection control are adequate.

GARAGE AND GROUNDS: The garage is attached to the house and locked at all times. The laundry room is in the garage locked and inaccessible. Facility has an adequate amount of emergency food and emergency water. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. There were no bodies of water noted.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LOVE CIRCLE HOME CARE LLC	FACILITY NUMBER: 565802407
	VISIT DATE: 05/19/2023

NARRATIVE

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Report Continued from LIC 809...

COMMON AREAS: Living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. The fire extinguisher was observed and fully charged. All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There is a staff bedroom for the live-in staff. There was a linen cabinet in the hallway with extra towels and linens.

RESTROOMS: The two resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured; the first bathroom measured at 131.7 degrees Fahrenheit at 9:44 a.m. and the second bathroom measured at 138.7 degrees Fahrenheit at 9:48 a.m. The Licensee adjusted the water temperature at the time of visit.

RECORDS: Records review began at 10:05 a.m.; one (1) resident’s record was reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Resident’s file is in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Out of the three (3) files reviewed, two (2) staff do not have current 1st Aid and CPR certification. However, the Licensee was able to obtain copies of current 1st aid and cpr certifications from vendor. The LPA also audited the current Administrator’s file, the Administrator Certificate expired on 01/04/2021 and has not been renewed since. The Licensee was able to show all necessary documents, training, and check ready to be mailed out to Sacramento.

MEDICATIONS: Medications review began at 11:20 a.m. The medications are centrally stored and locked in a cabinet in the kitchen. Medications are labeled and checked for expiration dates. No errors observed during the medication review.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LOVE CIRCLE HOME CARE LLC	FACILITY NUMBER: 565802407
	VISIT DATE: 05/19/2023

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Report Continued from LIC 809C...

Staff #1 (S1) at facility has criminal record clearance, but records reflect S1 is not associated to facility. Record review and interviews conducted revealed that S1 has worked at the facility for at least five (5) days. S1 was associated to the facility at the time of visit. Civil Penalties are being assessed in the amount of $500, $100 x 5 days.

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 issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/19/2023 02:47 PM - It Cannot Be Edited

Created By: Martha Arroyo On 05/19/2023 at 02:14 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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LOVE CIRCLE HOME CARE LLC	FACILITY NUMBER: 565802407
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/19/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(5)

87355(e)(2) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c)... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the licensee did not comply with the section cited above as S1 is not associated with the facility, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	Licensee associated S1 to the facility at the time of visit. POC has been met.

Type A

Section Cited

CCR

87303(e)(2)

87303(e)(2) Water supplies and plumbing fixtures shall be maintained as follows: Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observations, the licensee did not comply with the section cited above as three (3) out of three (3) facility faucets deliver hot water between 128- and 138-degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 05/19/2023
	Plan of Correction
1 2 3 4	The Licensee adjusted the thermostat during time of visit and has agreed to submit a hot water temperature log for five (5) to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit.

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:

Martha Arroyo

LICENSING EVALUATOR SIGNATURE:

DATE: 05/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/19/2023

LIC809 (FAS) - (06/04)

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