565850233-5-2-2022-29-AS-ASMH-CE2QZK-20220502123649

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850233
Report Date: 05/02/2022
Date Signed: 05/02/2022 12:37:26 PM

Document Has Been Signed on 05/02/2022 12:37 PM - 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:	LIGHTFULLY-MOONBEAM		FACILITY NUMBER:	565850233
ADMINISTRATOR:	RAFFERTY, CLODAGH		FACILITY TYPE:	772
ADDRESS:	1247 LA PERESA DRIVE		TELEPHONE:	(805) 692-5374
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY: 6		CENSUS: 0	DATE:	05/02/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Emily Eckstein		TIME COMPLETED:	12:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Ashley Smith arrived at the facility announced at 10:30 a.m. to conduct a pre-licensing inspection. The LPA met with Clinical Director Melissa Snyder, Administrator Emily Eckstein, and Program Director Stephen Canfield. The fire clearance was granted on 04/08/2022; in which rooms were cleared for ambulatory clients only. Component II was completed on 01/07/2022. Component III was completed during today’s visit.

The LPA toured the three-story home inside and outside with applicants to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

COMMON AREA: The first floor - which is considered the top level of the home - includes the kitchen, formal dining room, nursing office, staff room/garage with an attached bathroom, and a therapy/activity space. There are balconies on the first and second floor; however, access was limited for safety reasons. The second floor includes three (3) client bedrooms, an art room, the laundry room; and, the third floor - which is considered basement level - includes a client bedroom, common space, and a therapy room.

The common areas were appropriately furnished, and the lighting was adequate. There was a fireplace on the first floor, which was properly screened. The facility smoke alarm system is hard wired; the combination smoke detectors/carbon monoxide detectors were tested at 11:19 a.m. and were operable at the time of the visit. There are fully charged fire extinguishers on each floor. There was a functioning telephone on the premises. Emergency exiting plans/sketch were posted throughout the facility.

BEDROOMS: The facility designated four (4) bedrooms for client use. There are two rooms for double occupancy and two rooms designated for single occupancy. Rooms were set up with beds, nightstands, lamps, chests of drawers and closet space. Rooms #1, #2, and #3 are located on the second floor, and Room #4 was located on the third/basement level floor. Room #1 has a direct access to a balcony, yet access is limited for safety reasons. Lighting in the rooms appeared adequate.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022

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: LIGHTFULLY-MOONBEAM	FACILITY NUMBER: 565850233
	VISIT DATE: 05/02/2022

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MEDICATIONS: Medications will be kept locked and inaccessible in the nursing office. The applicant was advised to purchase additional items for the first aid kits, which was purchased during the visit.

THERAPY AND STAFF: Group and individual therapy can take place in the designated therapy rooms. Staff and client files will be stored electronically. Facility will have awake staff only; there are no staff sleeping quarters on the property.

LAUNDRY: The laundry room is on the second floor. Laundry detergent will be stored inaccessible.

GARAGE AND GROUNDS: The garage is accessible from the house and is kept locked. However, the garage was converted to staffing quarters. The exterior passageways were clean and clear of any obstructions. There will be covered patio area in the backyard with tables and chairs where clients can sit. There is a fireplace located outside; however, a screen is required. The screen was purchased during today's visit. There were no bodies of water noted. The facility plans to have an eight-passenger van on the premises for transportation use.

INFECTION CONTROL: The facility will have a central entry point for symptom screening and sanitation station for staff, clients and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the licensee can obtain additional supplies as needed. Staff are aware of the requirement as it pertains to vaccination and testing for incoming staff and clients. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Component III was conducted with the applicant during today’s visit.

The following needs to be corrected prior to licensure:
· Additional items for the first aid kit (tweezers, first aid manual, thermometer)
· Screen for outdoor fireplace
· Lighting fixtures need to be installed

Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 05/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/02/2022

LIC809 (FAS) - (06/04)

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