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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850273
Report Date: 10/06/2022
Date Signed: 10/06/2022 12:14:34 PM


Document Has Been Signed on 10/06/2022 12:14 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:NAVITA RESIDENCES YOUNGFACILITY NUMBER:
565850273
ADMINISTRATOR:VIJAYAKUMAR, KARTHIGAFACILITY TYPE:
740
ADDRESS:2024 YOUNG AVETELEPHONE:
(805) 917-2025
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
10/06/2022
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Karthiga VijayakumarTIME COMPLETED:
12:15 PM
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Licensing Program Analyst (LPA) Martha Arroyo conducted a pre-licensing visit to the above noted facility. The LPA met with applicant, KarthigaVijayakumar. This is a change of ownership from Navita Residence Young Ave #565801930 to Navita Residences Young #565850273. A dementia program was included in the plan of operation. A Hospice Waiver has been requested.

The facility is one story. At 9:35 a.m., a physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for five (5) non-ambulatory residents; and one (1) of bedridden residents. Bedroom #4 is approved for one (1) bedridden resident. The facility has six (6) private resident bedrooms. All resident rooms have direct exits to the outside. All resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, blanket and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. In addition, no bedroom was used as a passageway to another room, bath, or toilet. There is one (1) designated staff room. All rooms were free of odors. All window screens were clean and maintained in good repair. There are three (3) bathrooms in the hallway. One (1) is designated as a staff bathroom; and Room #1 has a private bathroom. The resident bathrooms have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was measured as follows: bathroom #1= 108.5*F, bathroom #2 = 111.4*F, bathroom #3 = 119.4*F, and kitchen -118.6*F, which falls within the allowable range of 105*F to 120*F. Resident and staff records are stored in a filing cabinet which is currently located adjacent to the kitchen. Medications are centrally stored in a locked cabinet adjacent to the kitchen. The first aid supplies were complete, including a thermometer and a current version of a first aid manual. They were stored in a cabinet adjacent to the kitchen. Kitchen knives are stored in a locked drawer in the kitchen island. The supply of dishes, utensils, pots, pans and drinkware is adequate. ...Report Continued on LIC 809C...
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/06/2022
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: NAVITA RESIDENCES YOUNG
FACILITY NUMBER: 565850273
VISIT DATE: 10/06/2022
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...Report Continued from LIC 809...

The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of nonperishable food is adequate. There are no pesticides or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, laundry and house cleaning supplies are stored in a locked cabinet located in the laundry room. No flies or other vermin were observed. The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, and activity supplies in the living room and dining area. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways and passageways to resident rooms and bathrooms. All ramps were secure and non-slippery and were positioned at the level where wheelchairs and walkers may enter and exit the facility safely. Auditory alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights. The facility has a furnace, which is able to heat rooms that residents occupy to a minimum of 68 degrees Fahrenheit; and, they have central air conditioning and are able to cool rooms to a comfortable range, not to exceed 85 degrees Fahrenheit. The facility smoke alarm system is hard wired. The smoke detector and carbon monoxide detectors were tested and functioned properly during the time of visit. There is one (1) fire extinguishers throughout the house. It is fully charged and does not exceed the expiration date of November 2022. There is a functioning telephone on the premises. The emergency exiting plans/sketch, emergency telephones numbers, and other required postings are posted by the entrance. The garage is not accessible from the house; the doors were locked. The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with tables and chairs where residents can sit. The back and sides of the house are separated from the front yard by gates. There are two (2) gates with a self-latching mechanism for persons to enter the front yard. There are no bodies of water on the premises at the present time.

Comp III was completed in conjunction with the visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA recommendation for licensure.

Exit interview conducted. A hard copy was provided via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:

DATE: 10/06/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/06/2022
LIC809 (FAS) - (06/04)
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