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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800269
Report Date: 11/18/2024
Date Signed: 11/18/2024 02:55:48 PM

Document Has Been Signed on 11/18/2024 02:55 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:M & L SOUTH BAY MAXI CAREFACILITY NUMBER:
405800269
ADMINISTRATOR/
DIRECTOR:		LITA C. LAZOFACILITY TYPE:
740
ADDRESS:1820 MOUNTAIN VIEW DRIVETELEPHONE:
(805) 528-7862
CITY:LOS OSOSSTATE: CAZIP CODE:
93402
CAPACITY: 6CENSUS: 0DATE:
11/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Lita LazoTIME VISIT/
INSPECTION COMPLETED:
03:10 PM
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Licensing Program Analyst (LPA) Rankin conducted a 1-year annual visit to the facility above. LPA met with Licensee/Administrator Lita Lazo and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Administrator. The following was inspected and noted during the annual visit:

Physical Plant & Environmental Safety: The facility has 8 bedrooms and 10 bathrooms, at time of visit there were no residents living at the facility. The facility currently has 2 live-in staff. The facility is clean, safe, and sanitary. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors which were tested and were working at time of visit. The showers have non-skid mats. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care and locked in cupboards. The facility has sufficient space inside and outside for activities and visiting. The facility has a pathway around the house and a sitting area in front yard for client use with shade. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation and infection control plan on file with the department. The Facility is operating in compliance with the granted fire clearance. The facility has current liability insurance and expires on 08/01/2025. The facility is approved for a capacity of 6 Non- Ambulatory, and Hospice approved for 3 residents.

Continued on 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/18/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION 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: M & L SOUTH BAY MAXI CARE
FACILITY NUMBER: 405800269
VISIT DATE: 11/18/2024
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Food Service: The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Emergency supply of food and water is available. Kitchen areas are kept clean and free insects and rodents.

Disaster Preparedness: The current emergency disaster forms were posted. The facility conducts quarterly disaster drills. The fire extinguishers were charged and last inspected 11/4/2024. Emergency exits and telephone numbers were posted. A set of keys is available for staff on all shifts to access full facility in an emergency. The facility has a back-up solar batter for emergencies.

Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger such as, sharps, and cleaners were locked or inaccessible to residents in care. The facility has exiting door alarms for the safety of residents in care.

Personnel Records & Training: The facility currently employes 2 staff and 2 Administrators. Staff records are kept confidential. LPA reviewed 2 staff files for 1st AID/CPR, Fingerprint clearances, Applications, Health exam with TB results, and Criminal Record statement. Annual training was complete with the exception of a a couple hours that are scheduled to occur in the next 30 days.

Residents Rights - All require postings were posted in the common area of the facility. The current license is posted.

Resident Records & Incident Reports: The facility keeps confidential files on each resident. Two files of past residents were reviewed for signed Admission Agreements, Medical Assessments LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights. Facility does submit incident reports to the department when required.

Medication cabinet was reviewed, there are no residents at the facility so the cabinet was empty.

Exit interview completed and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 11/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/18/2024
LIC809 (FAS) - (06/04)
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