565850595-3-14-2025-29-AS-TCAA-DERR56-20250314124238

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850595
Report Date: 03/14/2025
Date Signed: 03/14/2025 12:44:17 PM

Document Has Been Signed on 03/14/2025 12:44 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:	HOME SWEET HOME NEWMAN		FACILITY NUMBER:	565850595
ADMINISTRATOR/ DIRECTOR:	KANAKARAJ, KARTHIK		FACILITY TYPE:	740
ADDRESS:	5638 NEWMAN ST		TELEPHONE:	(805) 659-4427
CITY:	VENTURA	STATE: CA	ZIP CODE:	93003
CAPACITY: 6		CENSUS: 0	DATE:	03/14/2025
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Karthik "Raj" Kanakaraj, Karthiga Vijayakumar		TIME VISIT/ INSPECTION COMPLETED:	01:00 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) Teresa Camara conducted an announced pre-licensing visit to the above noted facility. The LPA met with applicant representatives/administrators Karthik "Raj" Kanakaraj and Karthiga Vijayakumar. This is a new facility. A dementia program was included in the plan of operation. A Hospice Waiver has been requested. The facility is one-story. A physical plant tour was conducted inside and out. An approved fire clearance was received, clearing them for six (6) non-ambulatory residents, one of which can be bedridden in room number one (1). The facility has six (6) private resident bedrooms. Bedroom one (1) is the only room with direct access to outside. Resident rooms have beds, night stands, 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 (if needed) 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 a designated staff room adjacent to the laundry room. All rooms were free of odors. All window screens were clean and maintained in good repair. There are three (3) full bathrooms in the hallways. All bathrooms have a shower with non-skid materials. The toilet and shower have grab bars. The hot water temperature was tested at 109.5F which is within the required range of 105F and 120*F. There is a staff room adjacent to the laundry room which remain locked. Resident and staff records are stored in a locked cabinet in the hallway. Medications are centrally stored in a locked cabinet in the kitchen. The first aid supplies were stored in the cabinet with medications. The first aid kit was complete, including a thermometer and a current version of a first aid manual. (continued on LIC809-C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

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: HOME SWEET HOME NEWMAN	FACILITY NUMBER: 565850595
	VISIT DATE: 03/14/2025

NARRATIVE

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(continued from LIC809)

Kitchen knives are stored in a locked cabinet in the kitchen. Stove burners are rendered inaccessible to the residents by removing them when not in use. The supply of dishes, utensils, pots, pans and drinkware is adequate. 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 (poisons) 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 laundry room. No flies or other vermin were observed.

The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment, games and/or activity supplies in the living room. The licensee employs an activities director for all of their facilities. There was sufficient space to accommodate both indoor and outdoor activities. Night lights were maintained in hallways 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. All rugs contained nonslip material underneath. There is a screened fireplace in the living room. 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 in each bedroom and flashlights with batteries stored in the medication cabinet. 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. During testing of the smoke alarm system, when one alarm was triggered all of the alarms sounded. The carbon monoxide detector was also tested and functioned properly during the time of the visit. There are two (2) fire extinguishers purchased on 11/1/2024. They appear to be fully charged.

(continued on LIC809-C)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

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: HOME SWEET HOME NEWMAN	FACILITY NUMBER: 565850595
	VISIT DATE: 03/14/2025

NARRATIVE

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(continued from LIC809-C)

The laundry room is adjacent to the garage and will remain locked at all times. Cleaning supplies will be stored in the laundry room. Extra towels and linens will be stored in a large cabinet in one of the bathrooms. Personal hygiene items (shampoos, soaps) were adequate and are stored in laundry room. Extra incontinence supplies are stored in bathrooms and bedroom closets. Personal Protective Equipment (PPE) is stored in the medication cabinet in the kitchen. There is a functioning telephone on the premises. The emergency exit plans/sketch are posted in the hallways. The emergency telephone numbers and other required postings are posted on the wall in the hallway near the laundry room.

The exterior passageways were clean and clear of any obstructions. There is a covered patio area at the back of the house with table and chairs where residents can sit. The entire property is fenced. The back and sides of the house are separated from the front yard by a self-latching gate. There are no bodies of water on the premises at the present time.The garage is accessible from the house; the door will remain locked.

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.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 03/14/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/14/2025

LIC809 (FAS) - (06/04)

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