191220759-5-12-2022-31-AS-NRED-CECQG2-20220512120848

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 191220759
Report Date: 05/12/2022
Date Signed: 05/12/2022 12:09:43 PM

Document Has Been Signed on 05/12/2022 12:09 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., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	KIM'S LOVE & CARE		FACILITY NUMBER:	191220759
ADMINISTRATOR:	MASTERSON, KIMBERLY YVONNE		FACILITY TYPE:	740
ADDRESS:	24107 VICTORY BLVD		TELEPHONE:	(818) 340-2213
CITY:	WEST HILLS	STATE: CA	ZIP CODE:	91307
CAPACITY: 6		CENSUS: 4	DATE:	05/12/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Kimberly Masterson		TIME COMPLETED:	12:15 PM

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At 10:33 a.m. on 05/12/2022, Licensing Program Analyst (LPA) Nicholas Reed conducted an unannounced annual inspection. LPA met with Administrator and disclosed the reason for the visit. LPA and Administrator toured the facility inside and out.

LPA conducted file review prior to the visit. The facility was last visited on 06/12/2019 for an annual visit. It is a single story building with 5 bedrooms, 2 bathrooms, kitchen, common areas, pool, and outdoor areas. It has an approved fire clearance for 6 nonambulatory residents. The facility serves residents with dementia. Approved hospice waivers for 1.

Entry: At the main entrance hung signs for the facility’s masking and vaccination requirements. The front perimeter is fenced. The front gate was unlocked with an inward facing, self-closing latch. The front yard was well maintained. LPA observed 2 dogs on the premise.

Screening: LPA was screened for infectious disease upon entry. The screening station contained a visitor log, digital thermometer, sanitizing wipes, hand sanitizer, N95 masks, and test kits. Hand sanitizer was locked up. LPA signed in through the visitor log. The visitor log documented visitor contact tracing information, symptoms, and temperature.

Common Areas: Walls, floors, ceilings, windows, and screens were clean and in good repair. At 11:03 a.m. LPA measured the room temperature to be 74 degrees Fahrenheit. A resident was watching television in the living room. Seating was arranged to accommodate social distancing. A fireplace had appropriate covering.

Bedrooms: The facility has 5 bedrooms. 2 bedrooms are designated for staff. The staff room near the pool was free of hazards and clean. The staff room at the northeast corner was locked. Of the bedrooms designated for residents, Bedroom #3 is private and Bedroom #1 and #2 are shared. All bedrooms contained a chair, nightstand, lamp, storage, and bed with adequate bedding. All furnishings were clean and in good condition. All emergency exits were unlocked and free of obstructions.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: KIM'S LOVE & CARE	FACILITY NUMBER: 191220759
	VISIT DATE: 05/12/2022

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Bathrooms: The facility has 2 bathrooms. All bathrooms contained liquid soap, paper towels, trash cans with tight fitting lids, grab bars near the toilet and shower, and a non-skid mat in the shower. LPA advised to place handwashing instruction signs in both bathrooms. At 11:02 a.m. LPA measured the water temperature in the large bathroom to be 105.1 degrees Fahrenheit.

Kitchen: LPA observed an adequate supply of perishable and non-perishable food. All surfaces were clean. The stove hood was sanitary. Sharp objects were locked under a counter. Cleaning solutions were locked under the sink. Medications were locked above a pantry. LPA observed signs for resident rights, resident councils, ombudsman contact, confidential complaints, emergency contacts, resident roster, facility license, and administrator certificate.

Laundry: A laundry area was located near the kitchen. LPA observed a washer and dryer in good condition. Detergent was locked above the appliances. LPA also observed a first aid kit by the appliances.

Safety: All emergency exit paths were free from obstructions. All handrails were secure. Ramps were free from hazards. Exit gates and doors were unlocked with inward facing, self-closing latches. Emergency Disaster Plan posted in the kitchen. At 11:04 a.m. LPA tested the carbon monoxide detector to be operational. At 11:05 a.m. LPA tested the smoke detector to be operational. At 12:02 p.m. LPA observed a fully charged fire extinguisher in the kitchen.

Outdoor areas: The back yard was well maintained. The pool was fenced and the gate was locked with a padlock. A covered seating area was located by the pool. Furniture was in good condition.

During today's inspection, the facility is in compliance with Title 22 regulations.

Exit interview conducted. Copy of report provided.

SUPERVISORS NAME: Cassandra Harris
LICENSING EVALUATOR NAME: Nicholas Reed
LICENSING EVALUATOR SIGNATURE:	DATE: 05/12/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/12/2022

LIC809 (FAS) - (06/04)

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