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Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609646
Report Date: 02/22/2024
Date Signed: 02/22/2024 01:20:57 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
01/26/2024 and conducted by Evaluator Sandra Urena
COMPLAINT CONTROL NUMBER: 29-AS-20240126134243
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:
02/22/2024
UNANNOUNCEDTIME BEGAN:
11:21 AM
MET WITH:Cilva ToumeTIME COMPLETED:
12:45 PM
ALLEGATION(S):
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Facility is not free from hazards.
INVESTIGATION FINDINGS:
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Licensing Program Analyst (LPA) Sandra Urena conducted a subsequent visit to deliver the findings pertaining to the allegations listed above. The LPA arrived and was greeted by staff. Staff contacted the administrator via phone. The LPA spoke with the administrator Cilva Toume and explained the reason for the visit. LPA read the report to the Administrator on the phone, and allowed staff representative to sign the reports.
On 01/26/2024, the Department received a complaint from a Reporting Party (RP) who observed and expressed concern about a hazard outdoors, in the side patio area. The RP observed two(2) refrigerators and or freezers on the side of the house plugged into a "makeshift electrical box". On 01/29/2024, Licensing Program Analyst (LPA) Sandra Urena conducted an initial 10-day visit to investigate the allegation listed above. The LPA and the administrator conducted a tour of the facility. The tour of the outside physical plant revealed that there is an outside electrical line that runs from an electrical box attached to the property to the additional outlet plug. Continues on LIC 9099C...
Substantiated
Estimated Days of Completion:
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 3
Control Number 29-AS-20240126134243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LOVELY COMMUNITY HEALTHCARE 2
FACILITY NUMBER: 567609646
VISIT DATE: 02/22/2024
NARRATIVE
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The administrator stated that the electrical cord was present since they open the facility in 2017. The administrator stated that the Fire Inspector Richard Martinez from the Ventura Fire Department will conduct an inspection on 01/30/2024 to ensure that the electrical box is withing compliance with the VFD. On 02/05/2024, at approximately 2:21p.m., LPA Urena spoke with the VFDI, Richard Martinez about the inspection conducted on 01/30/2024. The VFDI stated that the electrical box wiring was not up to code during the FI inspection. The wiring was open to the elements.

Based on the information received through the Ventura Fire Department Inspector, the allegation that the facility was not free safe of hazards is deemed Substantiated at this time.

Pursuant to Title 22 Regulations, deficiencies were cited (refer to LIC 9099-D).

Citations were issued. Exit interview conducted, a copy of the report, and Appeal Rights was issued.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
Page: 3 of 3
Control Number 29-AS-20240126134243
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION 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: LOVELY COMMUNITY HEALTHCARE 2
FACILITY NUMBER: 567609646
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/22/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
02/22/2024
Section Cited
CCR
87203
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CCR-87203- Operating Requirements
All facilities shall be maintained in conformity with the regulations adopted by the State Fire Marshal for the protection of life and property against fire and panic. This requirement is not met as evidenced by:

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The exposed wiring has been corrected at the time of this report.
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Based on the information obtained through observation and information received through the VFDI, the licensee did not comply in the section cited above, as the electrical box found outside the facility had wires that were exposed, which may pose a potential health and safety risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 02/22/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/22/2024
LIC9099 (FAS) - (06/04)
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