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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802441
Report Date: 09/16/2022
Date Signed: 09/16/2022 11:39:50 AM


Document Has Been Signed on 09/16/2022 11:39 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:
09/16/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Cilva ToumeTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management – Incident visit at the above facility at 9:30 a.m. The LPA met with Administrator, Cilva Toume and explained the reason for the visit. The purpose of this visit is to investigate an incident report submitted to the Department by the facility regarding Resident #1 (R1) refusing all his medication for two (2) days. Entrance interview.

During today’s visit, the LPA conducted a plant tour to ensure there are no immediate health and safety concerns. At 9:35 a.m., LPA attempted to speak with R1; however, R1 refused to open the door and speak with anyone. An interview was conducted with one staff at 9:20 a.m., and with the Administrator at 10:20 a.m. At 9:50 am., the LPA conducted a resident file review and obtained copies of pertinent documents. At 10:03 a.m., LPA called R1’s Pain Management Physician (PMP) and spoke with the Office Manager. PMP will call LPA at a later time.

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: 09/16/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/16/2022
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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