565802441-7-29-2022-29-AS-MARO-CGST3J-20220729142224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802441
Report Date: 07/29/2022
Date Signed: 07/29/2022 02:23:14 PM

Document Has Been Signed on 07/29/2022 02:23 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: 4	DATE:	07/29/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:05 PM
MET WITH:	Cilva Toume		TIME COMPLETED:	02:25 PM

NARRATIVE

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Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced visit to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 12:10 p.m. The last Annual conducted at this facility was on 6/20/2019. Upon arrival, the LPA was scanned and greeted at the door by Staff, Raymund. The Administrator, Cilva Toume arrived shortly after and was explained the reason for the visit. Entrance interview.

At 12:35 p.m., the LPA along with the Administrator began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The LPA observed one (1) refrigerator and one (1) freezer with a sufficient supply of perishable and non-perishable food. The LPA observed knives and sharps in a drawer next to the sink locked and inaccessible to residents at the time of visit.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed in the restrooms. Bathrooms were measure for hot water, at 12:42 p.m., the first bathroom measured at 125.8 degrees Fahrenheit, and at 12:44 p.m., the second bathroom measured at 124 degrees Fahrenheit. The Administrator had the water adjusted at the time of visit. …Report Continued on LIC 809C…

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022

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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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: 07/29/2022

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...Report Continued from LIC 809...

BACKYARD: There is a patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. LPA observed a secured pool in the backyard at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings at the time of visit. If needed, the facility has the capacity to self-isolate residents if the facility has a confirmed case of COVID-19.

The LPA and Administrator discussed staff vaccination requirements. All staff are fully vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

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 was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 07/29/2022 02:23 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: 07/29/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

Maintenance and Operation

(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) 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’s observation, the licensee did not comply with the section cited above as the resident bathroom faucets deliver hot water measured between 124- and 125.8-degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 08/05/2022
	Plan of Correction
1 2 3 4	The Administrator adjusted the thermostat during time of visit and has agreed to submit a hot water temperature log for five (5) days to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit to CCL by 8/05/2022.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 07/29/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/29/2022

LIC809 (FAS) - (06/04)

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