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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609646
Report Date: 11/17/2022
Date Signed: 11/17/2022 06:09:46 PM


Document Has Been Signed on 11/17/2022 06:09 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:LOVELY COMMUNITY HEALTHCARE 2FACILITY NUMBER:
567609646
ADMINISTRATOR:TOUME, CILVAFACILITY TYPE:
740
ADDRESS:1423 DOVER AVETELEPHONE:
(805) 494-1909
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
11/17/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Cilva ToumeTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Annual Inspection with focus on Infection Control.

LPA was greeted and screened at the door by staff. Reason for visit was explained. Administrator was contacted. LPA and Administrator toured the physical plant areas inside and outside to ensure facility is in compliance with Title 22 Regulations at approximately 2pm.

Following was observed:

There is a central entry point designated for universal screening by the entrance. The facility cleans the common areas at least twice daily. There are signs posted throughout the facility showing cough/sneeze etiquette and how to properly wash hands. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. LPA observed CDSS PINs printed in a binder accessible to both staff, residents and visitors. Sufficient supply of Personal Protection Equipment observed. Fire and carbon dioxide alarms tested and observed functioning properly.


Pursuant to Title 22, Division 6, facility observed to be compliant with Title 22 regulation.

Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 11/17/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/17/2022
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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