565850233-9-7-2022-29-AS-ASMH-CJ2ULL-20220907154055

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850233
Report Date: 09/07/2022
Date Signed: 09/07/2022 03:41:18 PM

Document Has Been Signed on 09/07/2022 03:41 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:	(858) 692-5374
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY: 6		CENSUS: 4	DATE:	09/07/2022
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME BEGAN:	01:20 PM
MET WITH:	Stephen Canfield		TIME COMPLETED:	03:45 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) Ashley Smith at the facility unannounced for a post-licensing inspection. The LPA met with Program Director Stephen Canfield and explained the reason for the visit. At 1:30 p.m., the LPA toured the three-story facility inside and outside to ensure there were no health and safety hazards and facility is in compliance with Title 22 Regulations. COMMON AREA: The common areas on all three floors were appropriately furnished, and the lighting was adequate. There was a fireplace on the first floor and on the outside patio, which both were properly screened. There are fully charged fire extinguishers on each floor. BEDROOMS: There are four (4) bedrooms for client use. There are two rooms for double occupancy and two rooms designated for single occupancy. All rooms were furnished appropriately with beds, night-stands, lamps, chests of drawers, chairs and closet space. Lighting in the rooms was adequate. BATHROOMS: There were hand-washing signs observed in all bathrooms that promoted good hand hygiene. The client tubs and showers are equipped with nonskid surfaces. The LPA measured the hot water throughout the facility, and the water registered within the appropriate range. KITCHEN: Kitchen knives and cleaning supplies are stored locked and inaccessible. Kitchen appliances were clean, and all appeared functional. The facility has a sufficient supply of perishable and non-perishable food. MEDICATIONS: Medications are kept locked and inaccessible in the nursing office. The LPA conducted a medication audit and no deficiencies were observed during the audit.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

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: 09/07/2022

NARRATIVE

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RECORDS: Records review began at 2:10 p.m. Staff files were reviewed for, but not limited to: background clearances, criminal record statement, health screening, personnel reports. All files were in order. Client files were reviewed for: care plans, medical records, admissions agreement, consent forms. All records were in order. The LPA compared the staff schedule for this location to the Guardian Background Check System and all staff were fingerprint cleared and associated to this facility at the time of the visit.

GARAGE AND GROUNDS: The garage was converted to a staff office. The exterior passageways were clean and clear of any obstructions. There was a patio area in the backyard with tables and chairs where clients can sit. There were no bodies of water noted.

INFECTION CONTROL: There 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 up to date regarding guidelines pertaining to visitation and vaccine requirements for 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. Policies pertaining to infection control practices are adequate.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/07/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/07/2022

LIC809 (FAS) - (06/04)

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