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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802441
Report Date: 11/12/2021
Date Signed: 11/12/2021 11:38:29 AM

Document Has Been Signed on 11/12/2021 11:38 AM - 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:LOVELY COMMUNITY HEALTHCAREFACILITY NUMBER:
565802441
ADMINISTRATOR:TOUME, CILVAFACILITY TYPE:
740
ADDRESS:52 W NORMAN AVENUETELEPHONE:
(805) 852-8770
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
11/12/2021
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Cilva ToumeTIME COMPLETED:
11:37 AM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an unannounced Case Management-Deficiencies visit today to issue a citation that was inadvertently recorded under a complaint visit. The purpose of the case management visit is to issue a citation for a deficiency observed during the course of the investigation of Complaint Control# 29-AS-20210824114220 observed on 08-26-2021.

On 08-26-2021 at 5:21pm, while conducting a plant tour with the Administrator, the LPA observed cleaning supplies which included ‘Krud Kutter Heavy Duty Cleaner’ unlocked under the sink in the common bathroom accessible to residents in care. During the visit, staff immediately locked and secured the cleaning supplies in a drawer making them inaccessible to residents in care. This deficiency was previously cleared by the licensee on 08-27-2021. Plan of Correction has been submitted and will be cleared.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted. A copy of the report and appeal rights were provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 11/12/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/12/2021
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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Document Has Been Signed on 11/12/2021 11:38 AM - It Cannot Be Edited


Created By: Martha Guzman-Chavez On 11/12/2021 at 10:39 AM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/12/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
08/26/2021
Section Cited
CCR
87705(f)(2)

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
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Staff placed toxic items in an inaccessible location during the facility visit. Staff stated that they will provide documentation of scheduled staff training regarding regulation 87705(f)(2) to CCL by 8/27/21.
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Based on LPA’s observations, the licensee did not comply with the section cited above as toxic items were observed in an accessible location to residents which posed an immediate health risk to persons in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:
DATE: 11/12/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/12/2021


LIC809 (FAS) - (06/04)
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