565802441-7-28-2023-29-AS-ECAS-CU6UWW-20230728155725

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802441
Report Date: 07/28/2023
Date Signed: 07/28/2023 03:57:54 PM

Document Has Been Signed on 07/28/2023 03:57 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 HEALTHCARE		FACILITY NUMBER:	565802441
ADMINISTRATOR:	TOUME, CILVA		FACILITY TYPE:	740
ADDRESS:	52 W NORMAN AVENUE		TELEPHONE:	(805) 852-8770
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	07/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Administrator-Cilva Toume		TIME COMPLETED:	04:05 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced for a required 1-year annual inspection today at 9:30 a.m. Upon arriving at the facility, the LPA was scanned and greeted at the door by staff. Administrator Cilva Toume arrived shortly thereafter and was explained the reason for the visit. At 10:00 a.m., the LPA, along with the staff and the administrator toured the physical plant areas 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: KITCHEN: At 10:00 a.m., the LPA observed the kitchen/dining area. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 10:10 a.m., LPA observed perishable food items in the refrigerator to be expired such as mayonnaise and dressings and observed 5 boxes of expired cereal in the pantry dates of expiration June 6, 2023. The Administrator was advised to monitor food items for expiration and expired food items were disposed of at the time of discovery. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. The facility consists of 8 (eight) total bedrooms, 6 (six) are designated for resident use and 2 (two) are designated for staff use. Staff bedrooms were observed and were occupied by staff. Administrator will provide updated facility sketch. Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: LOVELY COMMUNITY HEALTHCARE	FACILITY NUMBER: 565802441
	VISIT DATE: 07/28/2023

NARRATIVE

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RESTROOMS: Observed beginning at 10:20 a.m., restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Between 10:22 a.m. and 10:35 a.m., hot water measured at 114.9 and 118.0 degrees Fahrenheit in the resident restrooms.

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 6/13/2023. At 10:43 a.m., fire alarms 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 locked cabinet in under the kitchen sink and in the locked garage and laundry room which is only accessible from the outside backyard area.

RECORDS: Residents’ records review began at 11:35 a.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 2:00 p.m.; medications are centrally stored and locked in a cabinet in the kitchen. At 10:00 a.m. the LPA observed medications set aside for the day in an unlocked drawer above the locked medication cabinet. It was discovered that those medications were prepared medications for the day and medications for destruction. LPA reminded staff and administrator that all medications need to always remain locked when not being administered. Medication for Resident #1 (R1) were taken out of original bottle and transferred into non label bottle as they were refused by R1 and planned on being returned to pharmacy and staff explained that was the reason they were no longer in the original bottle. Administrator and staff were reminded that medications must always remain in original prescription bottles per regulation. Administrator and staff corrected the deficiency at the time of the visit.

Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

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: LOVELY COMMUNITY HEALTHCARE	FACILITY NUMBER: 565802441
	VISIT DATE: 07/28/2023

NARRATIVE

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INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. 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 LPAs obtained the following documents:

- LIC500 Personnel Report
- Liability Insurance

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. Failure to correct the deficiencies may result in civil penalties. Civil penalties were assessed during today’s visit.

Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/28/2023 03:57 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: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as medication was observed to be accessible in an unlocked drawer in the kitchen above the locked medication cabinet which poses an immediate health and safety of persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	The licensee agreed to the following: 1. Lock all accessible medicaitons. Plan of correction met at the time of the visit.

Type A

Section Cited

CCR

87465(h)(5)

Incidental Medical and Dental Care Services

(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as medication for R1 was discovered to be in an unlabled container which was identified to be refused medication and to be sent for destruction however medication was not labeled which poses an immediate health and safety risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	The licensee agreed to the following: 1. Ensure medications are in the approriatley labeled containers. 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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

Page: 4 of 5

Document Has Been Signed on 07/28/2023 03:57 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: 07/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

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
1 2 3 4	Based on observation, the licensee did not comply with the section cited above as multiple boxes of cereal were found expired along with mayonaise and dressings which poses a potential health and safety risk to persons in care.
	POC Due Date: 07/28/2023
	Plan of Correction
1 2 3 4	The licensee agreed to the following: 1. Dispose of expired food items. Plan of correction met at the time of the visit.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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 Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 07/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/28/2023

LIC809 (FAS) - (06/04)

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