565850390-4-8-2024-29-AS-KDUK-D45QQJ-20240408122224

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850390
Report Date: 04/08/2024
Date Signed: 04/08/2024 12:22:33 PM

Document Has Been Signed on 04/08/2024 12:22 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:	HOME SWEET HOME VAN BUREN		FACILITY NUMBER:	565850390
ADMINISTRATOR:	VALENCIA, GLORIA P.		FACILITY TYPE:	740
ADDRESS:	7520 VAN BUREN STREET		TELEPHONE:	(805) 659-4427
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY:	6	CENSUS: 0	DATE:	04/08/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Karthiga Vijayakumar, Karthik Kanakaraj, Gloria Valencia		TIME COMPLETED:	12:25 PM

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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 09:30AM. LPA met with applicant representative Karthiga Vijayakumar, Karthik Kanakaraj and Administrator Gloria Valencia. This application is for a Change of Ownership Application (CHOW) and the current licensed facility has residents in care. The applicant has obtained fire clearance for 5 (five) non-ambulatory and 1 (one) bedridden with a total capacity of six (6) residents. The applicant representatives indicated the proposed facility has a pending Dementia care plan and a pending hospice care waiver for 5 (five) residents. Applicant completed component II interview on 01/11/2024. During today's visit, all facility representatives completed component III with the LPA.

Beginning at 09:38AM, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 12:00PM and function properly at this time. Fire extinguisher was observed to be fully charged and purchased on 04/01/2024. Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. A working telephone is present.

The proposed facility has 8 (eight) bedrooms total, of which 6 (six) are private resident rooms and 2 (two) are designated as staff rooms. All resident bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. The proposed facility has 3 (three) bathrooms, 2 (two) are for shared resident use and 1 (one) is a staff restroom. LPA observed night-lights were present in the hallways. Hot water was measured in shared resident restroom and measured within the required range.

The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOME SWEET HOME VAN BUREN	FACILITY NUMBER: 565850390
	VISIT DATE: 04/08/2024

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non-perishable food is present, as well as, a seven-day supply of emergency water. Knives were stored in a locked drawer and cleaning supplies are stored in the locked garage. The facility contains a laundry area, containing locked cabinets. A locked medication cabinet was observed, as well as an inaccessible cabinet designated for record storage. First aid kit was observed and was complete.

Building and grounds were observed. Patio area contains a shaded seating area for resident use. Outdoor exit gate was observed to be self-closing and self-latching at this time. All passageways were observed to be clear of hazards.

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.

Exit interview conducted and a copy of the report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 04/08/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/08/2024

LIC809 (FAS) - (06/04)

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