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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850431
Report Date: 04/05/2024
Date Signed: 04/05/2024 02:56:43 PM

Document Has Been Signed on 04/05/2024 02:56 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:LOVING ARMS HOME, INCFACILITY NUMBER:
565850431
ADMINISTRATOR/
DIRECTOR:		CARRILLO, ROWENA MARANTALFACILITY TYPE:
740
ADDRESS:1534 WAKEFIELD AVETELEPHONE:
(213) 281-1439
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 0DATE:
04/05/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Rowena Carrillo, Kamran GhasriTIME VISIT/
INSPECTION COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted a pre-licensing visit to this property at 11:10AM. LPA met with applicant representatives Rowena Carrillo and Kamran Ghasri. The applicant has obtained fire clearance for 5 (five) non-ambulatory in bedrooms 2,3, and 4 and 1 (one) bedridden in bedroom 5 with a total capacity of 6 (six) residents. The proposed facility has a pending Dementia care plan and an approved hospice care waiver for 6 (six) residents. Applicant completed component II interview on 02/27/2024. During today's visit, Applicant representatives completed component III with the LPA.

Beginning at 11:20AM, LPA inspected the proposed facility for Fire Safety, Personal Accommodations, and Food Service. All hard-wired combination smoke alarm and carbon monoxide detectors were tested at 01:53PM and function properly at this time. Fire extinguisher was observed to be fully charged and recently purchased.

Paint, windows, blinds, and floors are in good repair. There are no firearms on the premises. The common living and dining areas are clean and properly furnished. A properly screened fireplace was observed in the living room. A working telephone is present. All required postings were observed in the common area. The facility contains a locked laundry room. All chemicals and cleaning supplies were observed locked inside the laundry room. A locked medication cabinet was observed in the kitchen, as well as a locked cabinet designated for record storage. First aid kit was observed to be complete. Garage was observed to be locked and inaccessible to future residents and contained storage for extra food and supplies.

The proposed facility has 6 (six) bedrooms total all of which are designated for private resident use. All bedrooms observed were furnished and contained beds, chairs, bedside tables and lamps. All beds have appropriate linens. There is also an ample supply of linen, towels and paper products. The proposed facility has 3 (three) bathrooms, 1 (one) is designated for shared resident use and 2 (two) for private resident use. LPA observed night-lights were present in the hallways. Hot water initially measured slightly higher than theReport Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/05/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: LOVING ARMS HOME, INC
FACILITY NUMBER: 565850431
VISIT DATE: 04/05/2024
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required temperature. Water temperature was adjusted during the visit, LPA retested the water, and it measured within the required range prior to the end of the visit.

The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present, as well as, a seven-day supply of emergency water. Knives and other sharps were stored in a locked cabinet under the kitchen sink.

Building and grounds were observed. Patio area contains a seating area for future resident use. Facility has an in-ground pool, which was observed to be fenced with an appropriate lock. Outdoor exit gates were observed to be self-closing and self-latching at this time. All passageways were observed to be clear of any hazards.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted and a copy of the report was provided.

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

DATE: 04/05/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/05/2024
LIC809 (FAS) - (06/04)
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