565850199-11-5-2021-29-AS-JROS-C8GREN-20211105125748

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850199
Report Date: 11/05/2021
Date Signed: 11/05/2021 12:58:23 PM

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:	HOME SWEET HOME DUVALI DR		FACILITY NUMBER:	565850199
ADMINISTRATOR:	VALENCIA, GLORIA P.		FACILITY TYPE:	740
ADDRESS:	36 DUVALI DR		TELEPHONE:	(805) 659-4427
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 0	DATE:	11/05/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:56 AM
MET WITH:	Shamin Mohamed - Applicant		TIME COMPLETED:	12:57 PM

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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Pre-licensing visit at the facility. LPA met with Applicant Representative Shamin Mohamed, Administrator Gloria Valencia and Assistant Administrator Karthiga Vijayakumar. Approved Hospice Waiver for 5 Hospice residents. Component III was conducted in conjunction with this pre-licensing visit.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. Facility has adequate water and nonperishable food supplies.

Facility has 6 private rooms, 1 private bathroom and 2 shared bathrooms. There are hand weights for exercise and games for activities. Medications, resident and staff records will be kept in a locked closet. Hot water temperature tested at 118.1 degrees Fahrenheit in resident bathroom during today’s visit. LPA observed smoke detectors and carbon monoxide detector operating properly and fire extinguisher properly charged. Fire clearance is approved for 6 non-ambulatory residents of which 1 may be bedridden in bedroom #1.

The following needs to be completed/proof submitted prior to the facility being licensed:

1. Updated facility sketch consistent with physical plant.

2. Chair in resident room.

3. Sufficient supply of blankets, sheets, mattress pads and towels.

Continued on 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

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: HOME SWEET HOME DUVALI DR	FACILITY NUMBER: 565850199
	VISIT DATE: 11/05/2021

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4. First Aid manual.

5. Front doorbell.

Exit interview conducted, today's report was reviewed and emailed to the Applicant and Administrator.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann Rosales	TELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:	DATE: 11/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021

LIC809 (FAS) - (06/04)

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