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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802441
Report Date: 09/09/2022
Date Signed: 09/09/2022 11:00:31 AM


Document Has Been Signed on 09/09/2022 11:00 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: 5DATE:
09/09/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Cilva ToumeTIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Incident visit at 9:00am. The LPA met with Administrator, Cilva Toume and explained the reason for the visit. The purpose of this visit is to investigate an incident submitted to the Department by the facility regarding Resident #1 (R1) self-neglecting and not allowing staff into their room. Entrance interview.

During today’s visit, the LPA conducted a plant tour to ensure there are no immediate health and safety concerns and interviewed the Administrator, one staff, and resident between 9:15am and 10:15 am. At 10:20 am., the LPA conducted a resident file review and obtained copies of pertinent documents relevant to the investigation.

Further investigation is required prior to issuing findings.

Exit interview conducted. A copy of the report was emailed to the Administrator.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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