565850107-2-24-2021-29-AS-KDUK-BYJMN6-20210224084501

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850107
Report Date: 02/22/2021
Date Signed: 02/24/2021 08:45:40 AM

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:	LOVIES BOARD AND CARE		FACILITY NUMBER:	565850107
ADMINISTRATOR:	BONOAN, SOPHIA		FACILITY TYPE:	740
ADDRESS:	3125 MICHAEL DRIVE		TELEPHONE:	(805) 407-1378
CITY:	NEWBURY PARK	STATE: CA	ZIP CODE:	91320
CAPACITY:	6	CENSUS: 0	DATE:	02/22/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	05:38 PM
MET WITH:	Sophia Bonoan		TIME COMPLETED:	06:51 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) Kelly Dulek conducted a pre-licensing inspection for this proposed facility on 2/22/2021 at 5:38PM. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with the use of "FaceTime" with applicant representative Sophia Bonoan. In addition, the residential care facility for the elderly (RCFE) inspection tool was not used during today’s inspection. A virtual tour of the facility was initiated at 5:38PM with the licensee representative. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. The following was noted: The facility consists of 5 total bedrooms – 4 will be private resident rooms and 1 shared resident room. There are 2 ½ bathrooms in the facility for resident use. Shared facility space includes a common living room, activity room, and dining area. Fire clearance was approved on 12/11/2020 for 6 Non-ambulatory residents. Licensee representative indicated the fire inspector had discussed bedridden fire clearance, but LPA noted the fire clearance issued is for non-ambulatory. Fire extinguishers were recently purchased and inspected during the fire inspection on 12/11/2020. Fire alarms/carbon monoxide detectors were tested at 6:02PM and were functional at the time of the virtual visit. LPA observed all required postings on the facility wall. Kitchen: The kitchen appeared clean and the appliances and fixtures functional at the time of visit. LPA observed a sufficient amount of non-perishable food at the facility, properly stored. Cleaning supplies are stored in a cabinet in the locked garage. Minimal cleaning supplies, knives and sharp objects are stored in the kitchen. Report Continued on LIC809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

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: LOVIES BOARD AND CARE	FACILITY NUMBER: 565850107
	VISIT DATE: 02/22/2021

NARRATIVE

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LPA advised obtaining a lock for the cabinet containing these items or alternate locked storage area to maintain these potentially hazardous items inaccessible to future residents. Medication: Medications and complete first aid kit will be stored in a locked closet. Resident/staff files will be maintained in a locked file cabinet. Bedrooms: There are 5 total bedrooms in the facility. 4 are private resident bedrooms and one is designated as a shared resident bedroom. All 5 client bedrooms were checked and were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens. Bathrooms: LPA observed all 2 1/2 bathrooms were clean, properly supplied and had functional fixtures. LPA observed all bathrooms to have grab bars and non-skid mats. Residents have sufficient amounts of supplies for personal hygiene. Due to the virtual nature of the visit, the hot water was unable to be measured at the time of the visit. Common Areas: These included the living room, dining area, and activity room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility has a dual-sided fireplace, which LPA observed to be properly screened. There is a designated telephone available for resident use. There are no power outlets in the hallways, therefore, nightlights are unable to be used in common hallways. The licensee representative plans to leave the hall light on to provide lighting to common bathrooms. Surrounding Grounds (Outdoors): There was a shaded area with proper furniture for outdoor use. Gates were observed to be self-closing and latching. There are no bodies of water on the premises. Garage: LPA also observed the locked garage, which contains emergency disaster supplies, locked chemical storage, an extra refrigerator/freezer, washer and dryer.

In addition, during today’s visit, LPA completed Component III with the licensee representative.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating under the new license until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted via telephone with administrator at 6:51PM. A copy of report was provided via email for signature.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/24/2021

LIC809 (FAS) - (06/04)

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