197607861-12-21-2022-29-AS-AASO-CMC2FS-20221221162201

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197607861
Report Date: 12/21/2022
Date Signed: 12/21/2022 04:23:23 PM

Document Has Been Signed on 12/21/2022 04:23 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:	DREAM HOME FOR SENIORS, LLC		FACILITY NUMBER:	197607861
ADMINISTRATOR:	ZENAIDA & RICARDO VELASCO		FACILITY TYPE:	740
ADDRESS:	20743 CLARK STREET		TELEPHONE:	(818) 835-9837
CITY:	WOODLAND HILLS	STATE: CA	ZIP CODE:	91367
CAPACITY: 6		CENSUS: 0	DATE:	12/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	Zenaida Velasco		TIME COMPLETED:	01:50 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) Angel Ascencio arrived at the facility unannounced to conduct a required Annual visit. This annual had a specific emphasis on infection control practices and procedures. LPA Ascencio met with Administrators Zenaida and Ricardo Velasco at 1:00 p.m. and explained the reason for the visit. Administrator mentioned to LPA that the facility does not have any residents at this time. Administrator was advised to call the Department once the facility admits their first resident. LPA Ascencio toured the physical plant areas inside and outside, with Administrator at 1:05 p.m. BEDROOMS: There are (4) four bedrooms designated for resident use. Bedroom #2 and Bedroom #4 have a direct exit to the exterior. The facility is capable of furnishing each room with clean linens, appropriate furnishings, and sufficient lighting for resident use. Bedroom #3 leads to a hallway, which allows for access to Bedroom #5 and Bedroom #6; however, those two rooms designated for staff. There is an exterior door that leads to Bedroom #5 and Bedroom #6. Staff are aware that once they have residents in Bedroom #3, staff would need to enter their rooms through the exterior door. RESTROOMS: There are (2) bathrooms designated for resident use. There is a bathroom designated for staff use only. Bathrooms are clean, sanitary, and in operating condition with grab bars and non-skid surfaces. The LPA advised the Administrators to ensure that bathrooms were stocked with paper towels and hand-washing signs prior to allowing resident admissions. Hot water temperature was tested throughout the home and was within normal ranges between 105.0 F and 120.0 F. COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating area and dining room furniture was observed to be in good condition. Chairs were observed to be at least 6 (six) feet apart for social distancing. Continued on LIC 809-C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: DREAM HOME FOR SENIORS, LLC	FACILITY NUMBER: 197607861
	VISIT DATE: 12/21/2022

NARRATIVE

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The common spaces included the living room, dining area, activity room, entertainment room and office area. The LPA observed cameras in all common spaces and exterior. All areas were clean, sanitary and in good repair. The LPA did not observed the required postings in the common hallway and Administrator was aware they are required to post posting throughout facility upon admission. Fire extinguishers were observed to be serviced within the last year. The facility smoke alarm system and carbon monoxide detector was tested and operated normally at the time of visit. The backyard has a covered outdoor area equipped with furniture for resident use. Two storage sheds were observed locked which included PPE supplies and additional cleaning supplies. The LPA observed a Laundry room which is located in an enclosed patio adjacent to the kitchen. Laundry detergents, cleaning supplies, pesticides, and/or toxins are also stored in the laundry area cabinet. The laundry room was observed to be locked and inaccessible. There are no bodies of water noted.

KITCHEN: Kitchen knives are stored in a locked cabinet in the kitchen. The supply of dishes,
utensils, pots, pans and drink ware is adequate. The freezer was maintained at zero degrees
Fahrenheit (0*F) and the refrigerator was maintained at 40*F. The supply of perishable and 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 under the kitchen sink. No flies or other vermin were observed.

INFECTION CONTROL: During today’s visit, LPA Ascencio spoke with Administrator regarding the
facility’s infection control practices at 1:30 p.m. There is 1 entry into the facility. Upon entry, the
facility has a central entry point for symptom screening. The LPA noted that the facility is allowing
visitors for both indoor and outdoor visitation. The LPA observed an adequate supply of Personal
Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The
facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation
room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of
COVID-19 at this time. The facility’s policies and procedures as it pertains to infection control are adequate.

No citations were issued during today’s visit.

Exit interview conducted, and a copy of the report provided to Admin via email.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angel Ascencio
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC809 (FAS) - (06/04)

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