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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802441
Report Date: 07/23/2024
Date Signed: 07/25/2024 04:06:10 PM


Document Has Been Signed on 07/25/2024 04:06 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:LOVELY COMMUNITY HEALTHCAREFACILITY NUMBER:
565802441
ADMINISTRATOR:TOUME, CILVAFACILITY TYPE:
740
ADDRESS:52 W NORMAN AVENUETELEPHONE:
(805) 852-8770
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
07/23/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
02:15 PM
MET WITH:Cilva Toume, Owner/AdministratorTIME COMPLETED:
07:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility for a required annual inspection. Upon arrival, the LPA was greeted at the door by staff. Administrator Cilva Toume was contacted by staff and arrived shortly thereafter.
At approximately 2:30 p.m, the LPA and staff/Ms. Toume began the physical plant tour (inside and outside) to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: COMMON AREAS: The LPA observed common area to be clean and properly furnished at the time of the visit. The LPA observed the fire extinguisher to be fully charged and last purchased on 05/23/2024. Smoke and carbon monoxide detectors were tested and functioned properly. The temperature was maintained at a comfortable level of 74 degrees F. Cleaning supplies and disinfectants are stored inaccessible under the kitchen sink cabinet, in the locked garage and laundry room which is only accessible from the outside area. KITCHEN: Kitchen/dining area observed. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. Supply of perishable food items good for two days and non-perishable food items for seven days observed at the facility during todays visit.
BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The facility consists of 6 (six) resident bedrooms. Staff bedrooms have been add (converted garage and laundry/closet space) observed and were occupied by staff. Administrator will provide updated facility sketch. RESTROOMS: Observed restrooms to be clean and sanitary and in operating condition with grab bars and non-skid surfaces during todays visit. Hot water measured at 118 degrees Fahrenheit in resident restrooms. RECORDS: Residents’ records review began at 5p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.
Due to time constraints, the LPA’s will return at a later date to complete the inspection. The following deficiencies were observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code. Exit interview conducted. Copy of the report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
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 5


Document Has Been Signed on 07/25/2024 04:06 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: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and records review, the licensee did not comply with the section cited above. Licensee/Administrator is using full rail for R1 and R2 (non-hospice residents). This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/22/2024
Plan of Correction
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Licensee/administrator switched R2 rail to half and removed the full rail from R1's bed during the visit today. Licensee also reported that she will provide the necessary steps and assistance to ensure residents safety while under her care. Corrected during todays 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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5


Document Has Been Signed on 07/25/2024 04:06 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: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/23/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303
Alterations to Existing Building or New Facilities (a) Prior to construction or alterations, all facilities shall obtain a building permit. (b) The licensing agency may require the facility to acquire a local building inspection where the agency determines that a suspected hazard to health and safety exists.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Licensee/Administrator converted the garage area and laundry/closet space in the hallway into a staff room. Licensee/Administrator confirmed live-in staff spend the night in the converted areas. These conversions were not approved or permitted for living/sleeping space. This poses a potential health,safety and personal rights risk to persons in care.
POC Due Date: 07/24/2024
Plan of Correction
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Licensee agreed to empty the areas and not allow staff to sleep in these areas immediately. Licensee shall submit an LIC500 to show 24hour awake staff on duty. Also Licensee may submit an LIC200 and updated facility sketch to obtain clearance for converted areas as staff room.
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: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 07/23/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/23/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5