565850107-3-24-2022-29-AS-MGCZ-CCTPTW-20220324113637

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850107
Report Date: 03/24/2022
Date Signed: 03/24/2022 11:37:35 AM

Document Has Been Signed on 03/24/2022 11:37 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:	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: 5	DATE:	03/24/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Sophia Bonoan		TIME COMPLETED:	11:35 AM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Guzman Chavez arrived at the facility unannounced to conduct a required annual visit at 9:45 a.m. This will be the first annual at this facility as they were pre-licensed on 2/22/2021. This annual has a specific emphasis on infection control practices and procedures. The LPA was greeted and scanned at the door by Administrator, Sophia Bonoan and was explained the reason for the visit. Entrance interview.

At 9:52 a.m., the LPA began the physical plant tour with the Administrator 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: The LPA observed the kitchen/dining area to be clean and kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed two refrigerators in the kitchen that were fully stocked 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 LPA observed two bathrooms for resident use. The first bathroom measured at 123.8 degrees Fahrenheit and the second bathroom measured at 125.8 degrees Fahrenheit.

...Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

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: LOVIES BOARD AND CARE	FACILITY NUMBER: 565850107
	VISIT DATE: 03/24/2022

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…Continued from LIC 809...

COMMON SPACES: The LPA observed the living room area which is clean and properly furnished with seating, a table, and television for resident use. The LPA observed two residents in the living room watching television during time of visit. The LPA observed the knives and sharps to be stored in a locked closet adjacent to the kitchen inaccessible to residents. Medications and First-Aid Kit were also observed in a locked closet adjacent to the kitchen.

GARAGE AND GROUNDS: The garage is locked and attached to the house. The LPA observed a covered patio area with patio furniture including a table and chairs for resident use. Facility has two fence gates that self-latch with a clear passageway for emergency exit use. There were no large bodies of water accessible to residents.

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, 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). Staff were observed wearing face coverings. All staff and residents are vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation.

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 to the Administrator via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/24/2022 11:37 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: LOVIES BOARD AND CARE	FACILITY NUMBER: 565850107
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/24/2022

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 LPAs observation, the licensee did not comply with the section cited above as two (2) out of two (2) facility restroom faucets delivers hot water measured at 123.8 and 125.8 degrees Fahrenheit, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 04/01/2022
	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 seven (7) days to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit.

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 Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/24/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/24/2022

LIC809 (FAS) - (06/04)

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