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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802441
Report Date: 04/29/2022
Date Signed: 04/29/2022 11:50:35 AM


Document Has Been Signed on 04/29/2022 11:50 AM - 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: 6DATE:
04/29/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Cilva ToumeTIME COMPLETED:
11:50 AM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced CASE MANAGEMENT- DEFICIENCIES visit to the above facility. The LPA met with Administrator, Cilva Toume to discuss the necessary documents in resident files as per regulation. Entrance interview conducted.

Per record review, it was revealed that Resident #1 (R1) was admitted to the facility on 4/11/2022, and the Administrator had not acquired a signed copy of R1’s Admissions Agreement by 4/18/2022. On 4/15/2022, LPA contacted Administrator regarding incident report pertaining to R1 contacting law enforcement because they felt facility was not assisting them to move in and settle down. Administrator stated they had yet to receive a signed copy of Admissions Agreement for R1. Interviews revealed facility gave paperwork to R1 to fill out and sign to turn in within seven (7) days. However, per interviews conducted, it was revealed that R1 had lost the Admissions Agreement and the Administrator had printed a new copy to give to R1. During the visit, R1 stated they would submit completed Admissions Agreement and submit to the facility before the end of the day.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. Appeal Rights discussed. A copy of the report will be provided via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-ChavezTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
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 04/29/2022 11:50 AM - 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: 04/29/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
05/02/2022
Section Cited

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87507(c) Admissions Agreement. Admission agreements shall be signed and dated, acknowledging the contents of the document, by the resident… and the licensee no later than seven days following admission…

This requirement is not met as evidenced by:
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Based on interviews and record review, the licensee failed to comply with the section cited above as R1 does not have a signed admission agreement on file which poses a potential personal rights risk to residents in care.
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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: Martha Guzman-ChavezTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 04/29/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/29/2022
LIC809 (FAS) - (06/04)
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