565850526-9-4-2024-29-AS-VCOY-D8STVU-20240904150430

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850526
Report Date: 09/04/2024
Date Signed: 09/04/2024 03:05:35 PM

Document Has Been Signed on 09/04/2024 03:05 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:	LOVIES BOARD AND CARE II		FACILITY NUMBER:	565850526
ADMINISTRATOR:	BONOAN, SOPHIA		FACILITY TYPE:	740
ADDRESS:	1253 CHRISTINA COURT		TELEPHONE:	(805) 407-1378
CITY:	CARAMILLO	STATE: CA	ZIP CODE:	93010
CAPACITY:	6	CENSUS: 0	DATE:	09/04/2024
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Sophia Bonoan		TIME COMPLETED:	03:30 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 (LPA) Valeria Conway conducted an announced Pre-Licensing Inspection to the above listed facility. Upon arrival LPA met with Administrator Sophia Bonoan. Entrance interview conducted. An application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL) on 04/17/2024. A Fire Clearance was approved for a maximum capacity of six (6), 1 (one) ambulatory and five (5) non-ambulatory residents, with a hospice waiver for three (3) on 04/16/2024. The facility consists of five (5) total bedrooms – 4 will be private resident rooms and 1 shared resident room. There are two (2) bathrooms in the facility for resident use. The proposed physical plant is a one (1) story single family dwelling located in a residential neighborhood of Camarillo, CA. This facility will be housing residents with dementia. There are no client residing in the facility at the moment. This facility doesn’t have a staff room, facility will provide 24/7 care. LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. Fire extinguisher is fully charged and recently purchased on 04/01/2024. Fire alarms/carbon monoxide detectors were tested at 10:37 A.M. and were functional at the time of the visit. LPA observed all required postings on the facility wall, a revised Emergency and Disaster Plan and a Plan of Operation in use. At 10:15 am a tour of the physical plant was conducted and the following observed: BEDROOMS: There are five (5) bedrooms, which Room #5 is for double occupancy. All bedrooms were equipped and supplied with appropriate furniture including but not limited to a bed, a chair, a night stan, a lamp and a chest of drawers, bedding, and linens. No client bedroom will be used as a public or general passageway to another room, bath, or toilet. There were no visible hazards or discrepancies observed. Continues on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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: LOVIES BOARD AND CARE II	FACILITY NUMBER: 565850526
	VISIT DATE: 09/04/2024

NARRATIVE

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Continued from LIC 809-C

BATHROOMS: There are two (2) bathrooms, LPA observed toilets and hand washing stations to be in operation condition. Solid waste containers are in good repair and have tight-fitting covers. Hygiene items of general use such as soap and toilet paper were observed in each bathroom. Facility provides each resident privacy and personal accommodations. Additionally, bathrooms had non-skid mats, and grab bars. Water temperatures were measured in all client bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.

KITCHEN: Appliances and fixtures appeared clean and functional. At the time of the visit, LPA observed a sufficient amount of dining and cook ware, non-perishable and perishable food to accommodate a maximum capacity of six (6) clients and facility staff for seven (7) days. Minimal cleaning supplies, sharps and knives will be stored in locked under-sink cabinets. There were no visible immediate hazards observed. At 10:20 A.M. hot water measured at 115.6 degrees Fahrenheit .

COMMON AREAS: These include the Family Room, Living Room and Dining Room. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. The facility has a fireplace in the dining room. LPA observed the fireplace to be properly screened. There is a designated telephone available and internet service for resident use. Facility has enough space to store clean common linen items such as bed sheets, towels, pillowcases, and mattress pads. LPA observed night lights in all hallways and passages to non private bathrooms. Facility has an auditory signal system in place at the time of the visit. Facility is equipped with fire door to enhance safety and prevent the spread of fire.

MEDICATION: Medications and complete first aid kit will be stored in a locked closet in the hallway next to room #5. At the time of the visit LPA observed five (5) individual empty plastic containers where medication will be store for each resident. Facility will properly document medication on the Centrally Store Medication and Destruction log.

Continues on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

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: LOVIES BOARD AND CARE II	FACILITY NUMBER: 565850526
	VISIT DATE: 09/04/2024

NARRATIVE

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Continued from LIC 809-C

SURROUNDING GROUNDS: Garden and yard are easily accessible to residents, and they are sufficient in size, comfortable and appropriately equipped for outdoor use. There was a shaded area with proper furniture for outdoor use. Gate was observed to be self-closing and latching. There are no bodies of water on the premises. LPA observed sufficient space to accommodate both indoor activities and outdoor activities for residents. All outdoor and indoor passageways were observed free of obstruction.

GARAGE: LPA also observed the locked garage, which contains emergency disaster supplies, locked chemical storage, washer and dryer. All residents’ and staff members’ files will be securely stored in the garage, locked in a file cabinet to ensure privacy and confidentiality. LPA observed sufficient amount of emergency water and emergency food at the time of the visit.

COMPONENT III ORIENTATION: A Component III Orientation was conducted with Administrator Sophia Bonoan during today's visit.

The following needs to be completed/Photos sent to LPA prior to licensure:

 No corrections at this time.

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. A copy of the Licensing Report was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 09/04/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/04/2024

LIC809 (FAS) - (06/04)

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