565850371-8-16-2024-29-AS-EMOY-D87T24-20240816142006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850371
Report Date: 08/16/2024
Date Signed: 08/16/2024 02:21:37 PM

Document Has Been Signed on 08/16/2024 02:21 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	HOMELIFE SENIOR LIVING LLC 7		FACILITY NUMBER:	565850371
ADMINISTRATOR:	LEVENTER, DEBBIE		FACILITY TYPE:	740
ADDRESS:	370 ARCTURUS STREET		TELEPHONE:	(805) 338-4448
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 4	DATE:	08/16/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:05 AM
MET WITH:	Dvora "Debbie" Leventer		TIME COMPLETED:	02:30 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 (LPAs) Kelly Dulek and Erica Mosley arrived at the facility unannounced at 9:05 a.m. to conduct a required annual visit. The LPAs entered the facility and was greeted by staff and shortly after met with Administrator Dvora “Debbie” Leventer. Rooms are cleared for 6 bedridden residents. The fire clearance was granted on 6/21/2023; in which bedridden residents are permitted in Bedroom B thru G. At 9:58 a.m., the LPAs toured the physical plant areas inside and outside with the Administrator to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer in the kitchen island. The supply of nonperishable food is adequate. The supply of dishes is adequate. Refrigerator and food pantry were checked for proper labels and expiration dates. Appliances in the kitchen were clean and functional. There is an adequate supply of emergency food and water. The fire extinguisher is in the kitchen which was fully charged and last serviced 06/03/2024. BEDROOMS: There are (7) seven bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (1) one room that is used as an office and to store files. The staff/office room is kept locked. All rooms A-G have direct access to the outside. Lighting in the rooms is adequate. (6) six out of (6) six private resident rooms were set up with beds, nightstands, lighting, chests of drawers, chairs and closet space. BATHROOMS: There are (7) seven full bathrooms. There are (6) six private bathrooms for resident use, the full bathroom at the entrance of the home next to Room A Staff Office is designated for staff and guests. The showers are equipped with nonskid surfaces. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between 107.7 – 119.3 degrees Fahrenheit. Continued on LIC 809-C

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOMELIFE SENIOR LIVING LLC 7	FACILITY NUMBER: 565850371
	VISIT DATE: 08/16/2024

NARRATIVE

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COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system tested at 2:00 p.m is hard wired; the smoke detectors were operable at the time of the visit. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted in the entrance area wall. Other required postings are also posted on the entrance area wall.
FILES: Resident and staff records are stored in the locked staff/office room. Resident Records were reviewed beginning at 11:23 a.m. and personnel records at 11:45 a.m. four (4) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Five (5) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.
LAUNDRY: The laundry area is in a locked laundry room next to the kitchen area. Laundry detergent and chemicals are stored inaccessible in the locked laundry room.

EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use located directly outside the sliding doors from the kitchen. There is common recreational area with additional covered patio area with furniture a mini golf area for resident use. There are no bodies of water noted on the premises. There is a self-latching gate located on the side passageway. There is no front yard gate or driveway gate. The garage is attached to the property and is used for additional storage. There are 3 other structures on the property which are licensed individually as part of the same ownership.

MEDICATIONS: Medications are in a locked closet located near the kitchen. The first aid supplies were complete, including a first aid manual. Medications review began at approximately 1:45 p.m. The medications are locked in a cabinet adjacent to the kitchen. Medications for two (2) out of four (4) clients were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records. INTERVIEWS: Four (4) staff interviews were conducted. Two (2) residents were interviewed during the inspection. No concerns were noted. No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report was provided.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 08/16/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/16/2024

LIC809 (FAS) - (06/04)

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