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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802407
Report Date: 06/10/2024
Date Signed: 06/10/2024 02:35:14 PM

Document Has Been Signed on 06/10/2024 02:35 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 LLCFACILITY NUMBER:
565802407
ADMINISTRATOR/
DIRECTOR:
TRAN, APRILFACILITY TYPE:
740
ADDRESS:1936 EDGEWOOD DRIVETELEPHONE:
(805) 527-2378
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 5CENSUS: 1DATE:
06/10/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:30 AM
MET WITH:April TranTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with staff and explained the reason for the visit. The Licensee / Administrator April Tran arrived shortly after. 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.

LPA inspected facility for fire safety, personal accommodations, and food service. The facility smoke alarm and combined carbon monoxide system is hard wired and was functional during the inspection. The fire extinguishers were observed to be fully charged and expire in September 2024.

LPA inspected kitchen at approx. 10am, Knives are kept inaccessible in a locked cabinet underneath the sink. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Cleaning products were observed stored in the cabinet to the right of the dishwasher and inaccessible to residents in care. Emergency food was observed to be sufficient at this time.  LPA observed medication, along with resident and staff records to be kept inaccessible in kitchen cabinets.

The bedrooms were observed to be properly furnished with a bed, night stand, and sufficient lighting for each client The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed bathroom to be clean, properly supplied and had functional fixtures. The hot water was measured in the bathroom within 105 - 120 degrees Fahrenheit. The bathrooms were sufficiently stocked with supplies and paper towels. LPA observed required postings throughout the common spaces. LPA observed Two (2) closets in hallway to store PPE, Linen and other supplies for facility use.

The common areas were appropriately furnished, and the lighting was adequate. There are games and/or activity supplies in the living room.  
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/10/2024
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 2
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: 06/10/2024
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Continued from 809
There was sufficient space to accommodate indoor activities. Night lights were maintained in hallways and passageways to non-private bathrooms. 
In the rear of the facility, LPA observed a shaded patio with furniture designated for outdoor use.  There is sufficient room to conduct outdoor activities. The exterior passageways were clean and clear of any obstructions. The LPA observed one (1) self-latching gate for emergency use. There are no bodies of water on the premises at the time of the visit. There is an attached garage that is kept locked and inaccessible to residents in care. LPA observed a laundry area as well as storage for extra supplies for facility use.
In addition, the physical plant is consistent with the submitted facility sketch/floor plan.  The facility was set at a comfortable temperature. Fireplace  was observed to be properly screened.  Staff room next to the front entry was observed to be inaccessible to residents in care and empty at this time.

Records review began at approx. 10:45am, client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training.  All records were observed to be in order at this time.  Last emergency disaster drill was conducted April 30, 2024.

Medications review began at approximately approx  1:30pm, Medications were observed to be properly documented on the centrally stored medications and destruction record at this time. The first aid supplies were complete , including a thermometer and a current version of a first aid manual. First aid was observed to be stored inaccessible in the medication cabinet as well.

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 and symptoms of COVID. 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 case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate at this time.
During the visit, LPA interviewed staff. LPA also obtained the following documents - Census, Staff schedule,  and updated Limited Liability insurance.
Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2024
LIC809 (FAS) - (06/04)
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