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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801597
Report Date: 10/17/2024
Date Signed: 10/17/2024 03:20:03 PM

Document Has Been Signed on 10/17/2024 03:20 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/
DIRECTOR:		DIORENA ROCK/ MICHEAL V.FACILITY TYPE:
740
ADDRESS:28 WALES STREETTELEPHONE:
(805) 230-3818
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
10/17/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:42 AM
MET WITH:Diorena "Rocky" RockTIME VISIT/
INSPECTION COMPLETED:
03:25 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 10:42AM. The LPA was greeted by facility staff and informed them of the reason for the visit. LPA was informed Administrator was not available at the time of arrival. Administrator arrived at 11:10AM. Entrance interview conducted.

Beginning at 11:47AM, the LPA and the 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. The following was observed:

Fire extinguisher was observed to be fully charged and last serviced 02/21/2024. Hardwired combination carbon monoxide and smoke detectors and fire door are connected to the facility's Nest system, which records daily functionality of the systems. All systems were functional at the time of the visit.

BEDROOMS/BATHROOMS: The LPA inspected the bedroom and bathroom areas. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) designated resident rooms and 1 (one) staff room. The facility contains 2 (two) restrooms; 1 (one) of which is designated for shared resident use and 1 (one) is for staff and guest use. Resident restroom was clean and sanitary and in operating condition with grab bars and non-skid surfaces. The hot water temperature measured at 117.1 degrees Fahrenheit in the hallway bathroom.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature throughout the visit.

KITCHEN: The LPA toured the kitchen/food service area. Knives and additional cleaning supplies are stored inaccesible and locked in the garage. Kitchen appliances were in operable condition. The facility had a sufficient supply of perishable and non-perishable food at the time of visit. Continued LIC 9099-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/17/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: 10/17/2024
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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There is a side gate that is single latched. There is a gated and locked pool which is inaccessible to residents in care. Passageway did have items stored on both sides, limiting the walkway. LPA advised to move items to allow for easier passage. The garage is where the washer and dryer are held, including additional refrigerator with perishable food items. Emergency food and water are kept in the garage.

RECORDS: Records will be reviewed during the annual continuation visit



MEDICATIONS: Medications review began at 02:03PM; medications are centrally stored and kept locked in a kitchen cabinet. Medications were observed for 2 (two) residents. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's emergency disaster plan. Emergency disaster plan was updated annually, as required. Infection control plan will be reviewed during the annual continuation visit.

INTERVIEWS: During today's visit, LPA interviewed 1 (one) resident and 2 (two) staff. No concerns were noted.

Due to time constraints, LPA will return at a later date to continue the inspection.

No deficiencies cited. Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/17/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/17/2024
LIC809 (FAS) - (06/04)
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