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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609646
Report Date: 02/27/2024
Date Signed: 02/27/2024 06:46:22 PM


Document Has Been Signed on 02/27/2024 06:46 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: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: 5DATE:
02/27/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
03:15 PM
MET WITH:Cilva ToumeTIME COMPLETED:
06:45 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. The LPA met with Administrator Cilva Toume and explained the reason for the visit. Entrance interview.

The reason for today's inspection is to follow up on a self-reported death report received on 02/26/2024. The report pertains to the death of Resident #1 (R1). Per the information received, the circumstances surrounding the death of Resident #1 on 2/20//24 may be questionable and needs to be investigated. Emergency services and law enforcement were called to the facility on the day of Resident #1's death.

During today's visit, the LPA conducted interviews with staff, R1's responsible party, conducted a brief tour of the facility and obtained copies of pertinent documents.

This incident was referred to Community Care Licensing Investigations Branch (IB) for review. Further investigation is required prior to issuing findings. An investigator or the LPA will return at a later date.

Exit interview conducted. A copy of the report was issued to the Administrator Cilva Tourne.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 02/27/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/27/2024
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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