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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850233
Report Date: 05/16/2023
Date Signed: 05/17/2023 08:26:05 AM

Document Has Been Signed on 05/17/2023 08:26 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:LIGHTFULLY-MOONBEAMFACILITY NUMBER:
565850233
ADMINISTRATOR:RAFFERTY, CLODAGHFACILITY TYPE:
772
ADDRESS:1247 LA PERESA DRIVETELEPHONE:
(858) 692-5374
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY: 6CENSUS: 1DATE:
05/16/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:20 PM
MET WITH:Melissa Rabinoff SnyderTIME COMPLETED:
04:53 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 1:20 p.m. LPA met with Administrator Melissa Rabinoff Snyder and explained the reason for the visit. This is a social rehabilitation facility which houses clients typically for a maximum of 30 days.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The fire extinguishers appeared fully charged and were last inspected 5/2/23. The carbon monoxide and smoke alarms were tested and functioned properly during the visit.

KITCHEN: The kitchen was clean and appliances all appeared operable. The facility has a sufficient supply of perishable and non-perishable food. There was a table in the kitchen for dining. BEDROOMS: The LPA observed two double-occupancy rooms and two single-occupancy rooms which were appropriately furnished, clean and had sufficient lighting. RESTROOMS: There were 4 bathrooms which were clean, sanitary and in operating condition. COMMON SPACES: The art room, living room, dining room and group therapy room were all appropriately furnished and in good condition. The LPA observed the required postings throughout the facility. The backyard and decks were equipped with furniture for clients' use.

MEDICATION: The medication room is located off of the kitchen and remains locked when not in use. Medications are also locked within the locked room. Medications appeared to be given as prescribed.

CLIENT RECORDS: Client records were reviewed and appeared to be completed as required. LPA interviewed the one client currently residing at the facility. The client had no complaints and was happy with the staff and services at the faciity. STAFF RECORDS: All scheduled staff are fingerprint cleared and associated to this facility. Staff records indicate staff have required training for their positions. All other staff records were complete. LPA interviewed staff at the facility. All staff communicated well informed responses.

Exit interview conducted. A copy of the report was emailed to the Administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 05/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/16/2023
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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