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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801597
Report Date: 10/14/2022
Date Signed: 10/14/2022 12:01:08 PM

Document Has Been Signed on 10/14/2022 12:01 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:A LOVING HEART SENIOR CAREFACILITY NUMBER:
565801597
ADMINISTRATOR:DIORENA ROCK/ MICHEAL V.FACILITY TYPE:
740
ADDRESS:28 WALES STREETTELEPHONE:
(805) 230-3818
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
10/14/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Rocky Diorena - Administrator TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA was screened by Rocky Diorena - Administrator and LPA explained the reason for the visit. This annual had a specific emphasis on infection control practices and procedures.
 
At approximately 9am, LPA along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. Fire extinguishers were observed fully charged and last serviced in February of 2022. At 9:05am, LPA observed (5) residents having breakfast at the dining table. (1) client was at a doctor's appointment. 
 
Kitchen appliances were observed to be relatively clean and appeared to be in operable condition. LPA observed a  sufficient supply of perishable and non-perishable food properly stored. Sharp objects were observed stored in a locked drawer to the left of the sink.
 
LPA observed resident bedrooms furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. Entryway closet was observed to store a (30) day supply of PPE, toiletries, cleaning supplies and coats. Hallway closet was observed to store clean linen and network devices.
 
Restrooms were observed to be relatively clean, sanitary and in operating condition with grab bars and non-skid mats. Hot water measured between 105 - 120 degrees Fahrenheit. Infection control signs were observed  posted throughout facility to promote hand washing, cough/sneeze etiquette, and physical distancing
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/14/2022
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: A LOVING HEART SENIOR CARE
FACILITY NUMBER: 565801597
VISIT DATE: 10/14/2022
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Continued from 809

LPA observed the back patio, which has a covered outdoor area with a appropriate seating for outdoor use. There is a self-latching gate on the side and back of the facility designated for an emergency exits. There is a swimming pool located in the rear of the facility. LPA observed pool to be inaccessible to residents in care with a high fence and its' entrance locked. LPA also observed a shaded patio area located in the front of the facility. LPA observed furniture appropriate for outdoor use. Garage is attached to the facility and was observed to be inaccessible to residents in care. Garage was observed to store  (2) refrigerators and  non-perishable foods all properly stored. LPA also observed  cleaning supplies, incontinence supplies and miscellaneous supplies for facility use.

 INFECTION CONTROL: The LPA spoke with Administrator regarding the facility’s infection control practices. upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection 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 each bedroom as an isolation room  if the facility has a confirmed case of COVID-19. COVID-19 testing will be conducted twice a week when there is a positive case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate at this time.
 
No deficiencies were observed at this time. Exit interview conducted. Report issued and a copy of the report was provided via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 10/14/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/14/2022
LIC809 (FAS) - (06/04)
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