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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802441
Report Date: 07/09/2025
Date Signed: 07/09/2025 03:29:16 PM

Document Has Been Signed on 07/09/2025 03:29 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:LOVELY COMMUNITY HEALTHCAREFACILITY NUMBER:
565802441
ADMINISTRATOR/
DIRECTOR:		TOUME, CILVAFACILITY TYPE:
740
ADDRESS:52 W NORMAN AVENUETELEPHONE:
(805) 852-8770
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
07/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:08 AM
MET WITH:Cilva Toume, Licensee Representative /Administrator
Vana Barberis, Assistant Administrator 		TIME VISIT/
INSPECTION COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 10:00 a.m. Upon arrival, LPA Mosley was greeted by staff who called the Administrator to inform them of the visit. The Administrator, Cilva Toume and Vana Barberis Assistant Administrator arrived shortly after and the reason for the visit was explained. Entrance interview.

INTERVIEWS: From 10:05 a.m. – 10:29 a.m. two (2) staff and four (4) resident interviews were conducted. Staff interview revealed that staff are knowledgeable in Resident rights, different forms of abuse, and reporting procedures. Resident interviews revealed that no concerns were noted or voiced at the time of the visit.

The LPA and 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.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 1:30 p.m., hardwire combination of smoke / carbon monoxide detector and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 05/05/2025. The emergency telephone numbers are posted in common hallway. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 07/09/2025 and are conducted quarterly. Activities were observed in the common areas. The fireplace in the living room was adequately screened. There is a functioning telephone on the premises.

Report Continued from LIC 809-C PAGE 2...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/09/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441
VISIT DATE: 07/09/2025
NARRATIVE
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(PAGE 2) Report Continued from LIC 809...
BEDROOMS: There are six (6) total bedrooms in the facility; six (6) bedrooms are designated as private, single occupancy, resident rooms. There are two (2) additional staff rooms / areas (converted garage and laundry/closet space) that have been added / converted without permits, however a LIC200 was submitted on 07/23/2024 to document the change and schedule a fire clearance inspection. The staff rooms / areas are kept locked at all times.

RESTROOMS: There are three (3) restrooms. Two (2) are designated as shared / common restrooms and one (1) is designated as a private resident restroom. Resident restrooms were observed to be equipped with nonslip surface. Grab bars were observed in the restrooms. The restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured all resident restrooms and ranged between 113.2- 116.1 degrees Fahrenheit, all within the required range.

KITCHEN: The LPA inspected the kitchen/food service area at 11:16 a.m. Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. There were three (3) meat products in the freezer that did not have a date which poses/posed a potential health, safety or personal rights risk to persons in care. At the time of the visit the date was added. The kitchen faucet was measured for hot water temperature, and it measured 110.8 degrees Fahrenheit at 11:17 a.m. Cleaning supplies and other chemicals are kept in a cabinet under the sink. At 11:18 a.m. the cabinet under the sink was unlocked with multiple cleaning chemicals / solutions which poses/posed an immediate health, safety or personal rights risk to persons in care. At the time of the visit the Administrator locked the cabinet and spoke to staff about the importance of ensuring chemicals are locked and inaccessible to residents in care. LPA observed an adequate amount of emergency food and water in a closet / pantry adjacent to the kitchen.

BACKYARD: The entire property is fenced. There is a laundry area /room, with a washer and dryer that remains locked at all times, laundry detergent was observed. The backyard has a portable umbrella for shade with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. LPA observed two (2) self-latching gates. Facility has an in-ground pool, which was observed to be fenced with an appropriate lock. Emergency exits and passageways were observed free of obstructions and hazards. Report Continued from LIC 809-C PAGE 3...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
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: LOVELY COMMUNITY HEALTHCARE
FACILITY NUMBER: 565802441
VISIT DATE: 07/09/2025
NARRATIVE
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(PAGE 3) Report Continued from LIC 809-C PAGE 2...

RECORDS: Record review began at approx. 11:36 a.m. Resident Records were reviewed beginning at 11:36 a.m. and Personnel Records at 12:23 p.m. Six (6) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All records were in order. Six (6) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

MEDICATIONS: Medications review began at approximately 2:35 p.m. The medications are in a locked drawer located in the kitchen . Medications for three (3) residents were reviewed. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications reviewed were found to be self-administered as prescribed and documented on the centrally stored medication and destruction records. No errors observed during review.

LPA obtained the following documents - Resident roster LIC 9020, Staff roster -LIC 500, and a copy of the Limited Liability insurance.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. The Licensee was made aware that failure to correct the deficiencies may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/09/2025
LIC809 (FAS) - (06/04)
Page: 6 of 6
Document Has Been Signed on 07/09/2025 03:29 PM - It Cannot Be Edited


Created By: Erica Mosley On 07/09/2025 at 02:54 PM
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: 07/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as cleaning solutions were unlocked and accessible to residents which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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At the time of the visit the Administrator locked the cabinet and spoke to about the importance of ensuring chemicals are locked and inaccessible to residents in care. Administrator will review regulation 87309 (a) with staff.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Erica Mosley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/09/2025 03:29 PM - It Cannot Be Edited


Created By: Erica Mosley On 07/09/2025 at 02:54 PM
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: 07/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87470(c)
Infection Control Requirements
(c) An Infection Control Plan shall be developed by the licensee and shall be included in the Plan of Operation required by Section 87208.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above in the infection control plan was not available which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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At the end of the visit the infection control plan was submitted. POC CLEARED.
Type B
Section Cited
CCR
87309(a)(2)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. (2) Any items in subsection (a)(1) that are transferred from their original container to another container shall have a legible label that indicates:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation , the licensee did not comply with the section cited above in three (3) meat items did not have proper labels which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 07/09/2025
Plan of Correction
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At the time of the visit dates and labels were added to the three (3) meat items. POC CLEARED
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Erica Mosley
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/09/2025


LIC809 (FAS) - (06/04)
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