565850302-6-14-2023-29-AS-KLOZ-CSSUSM-20230614155035

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850302
Report Date: 06/14/2023
Date Signed: 06/14/2023 03:51:31 PM

Document Has Been Signed on 06/14/2023 03:51 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 - HALO		FACILITY NUMBER:	565850302
ADMINISTRATOR:	WOODHOUSE, DEANNA		FACILITY TYPE:	772
ADDRESS:	949 EL SEGUNDO DRIVE		TELEPHONE:	(805) 852-5457
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY: 6		CENSUS: 0	DATE:	06/14/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Emily Eckstien		TIME COMPLETED:	04:00 PM

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Licensing Program Analyst (LPA) KaSandra Lopez arrived at the facility announced at 1:00 PM to conduct a pre-licensing inspection. The LPA met with Regional Vice President Emily Eckstien, Administrator and Program DIrector Deanna Woodhouse , Program Manager Allison Prather, and Director of Clinical Operations, Yvette Llanos The fire clearance was granted on 01/05/2023 for six ambulatory clients only. Component III was completed during today’s visit.

The LPA toured the single-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 and the Health and Safety Code.

COMMON AREA: The facility common areas includes the group therapy room, kitchen, formal dining room, family room, nursing office, therapy office, and staff office in the garage. The common areas were appropriately furnished, and the lighting was adequate. The facility has a central entry point for symptom screening and sanitation station for staff, clients and visitors. There was a fireplace in the family room which is properly screened. The facility smoke alarm system is hard wired; the combination smoke detectors/carbon monoxide detectors were tested and were operable at the time of the visit. There are three fire extinguishers in the home. Proof the fire extinguishers were purchased or serviced within the last year needs to be provided. There was a functioning telephone on the premises. Cleaning supplies and hygiene items are stored in a locked cabinet in the hallway. Facility had a sufficient supply of towels and linens. Emergency exiting plans/sketch were posted throughout the facility.

BEDROOMS: The facility designated three (3) bedrooms for client use. Each bedroom has two beds, night stands, chairs, and lights. Bedroom #1 has a screened fire place. Bedroom # 1's closet does not currently allow for clothing to be hung and Bedroom #2 is missing a minimum of two drawers or eight cubic feet for each client.

MEDICATIONS: Medications will be kept locked and inaccessible in a medication cart in the nursing office. First aid supplies were reviewed and are complete. The facility has a sufficient supply of personal protective equipment and a plan in place if an isolation room is needed. Report continued on LIC 809-C.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

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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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 - HALO	FACILITY NUMBER: 565850302
	VISIT DATE: 06/14/2023

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THERAPY AND STAFF: Group and individual therapy will 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.

RESTROOMS: The facility has one private restroom in bedroom #1 and three common restrooms for client use. Restrooms were observed to be clean and sanitary with hand soap, paper towels, and toilet paper. The hot water temperature in bedroom #1 measured at 110 degrees F.

GROUNDS: There is a covered area in the backyard with outdoor seating. There is also a screened fireplace outside. The backyard area has a pool and jacuzzi that is inaccessible to clients by a pool cover. The exterior passageway to the front yard currently has a gate that is locked from the front of the facility and is not a clear passageway to exit the property. The front yard currently has a water fountain operating with more than two inches of water. The laundry room is accessible from the outside patio. Laundry detergent will be stored inaccessible to clients.

The following needs to be corrected prior to licensure:

1. Submit proof the facility has a supply of emergency lighting and back up batteries.

2. Submit proof the fire extinguishers have been serviced or purchased within the last year.

3. Submit proof Bedroom #1 has a rod to hang client clothing.

4. Submit proof Bedroom #2 has minimum of two drawers or eight cubic feet for each client.

5. Plan on how they will secure the water fountain in the front yard.

6. Submit proof the exterior passageways are clear of any obstructions.
This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Kasandra Lopez
LICENSING EVALUATOR SIGNATURE:	DATE: 06/14/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/14/2023

LIC809 (FAS) - (06/04)

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