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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850557
Report Date: 10/15/2024
Date Signed: 10/15/2024 11:59:58 AM

Document Has Been Signed on 10/15/2024 11:59 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:NAVITA RESIDENCES ASHWOODFACILITY NUMBER:
565850557
ADMINISTRATOR/
DIRECTOR:		VIJAYAKUMAR,KARTHIGAFACILITY TYPE:
740
ADDRESS:390 N ASHWOOD AVETELEPHONE:
8053691255
CITY:VENTURASTATE: CAZIP CODE:
93003
CAPACITY: 6CENSUS: 0DATE:
10/15/2024
TYPE OF VISIT:PrelicensingANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Karthiga VijayakumarTIME VISIT/
INSPECTION COMPLETED:
12:10 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a pre-licensing inspection. LPA met with administrator Karthiga "Karthi" Vijayakumar.

The applicant has obtained fire clearance for five (5) non-ambulatory residents in bedrooms one (1) through five (5) and one (1) bedridden resident in room six (6) for a total capacity of six (6) residents. The proposed facility does have a dementia care plan and a hospice waiver for five (5). During today's visit at 10:55 a.m., administrator completed component III with the LPA.

Beginning at 10:04 a.m., LPA inspected the proposed facility for fire safety, personal accommodations, and food service. The smoke alarms and carbon monoxide detectors were tested and functioned properly. The fire extinguishers were purchased on 8/3/2024 and appeared fully charged.

Bedrooms: The proposed facility has seven (7) bedrooms total, one (1) of which is designated for staff use and six (6) are private resident rooms. The current model bedroom (room 5) was fully furnished and contained a bed, chair, bedside table, dresser, and lighting. The bed had appropriate bedding. There is furniture available for the other rooms if a new resident chooses to have a fully furnished room. There is an ample supply of linens and towels stored in the cabinets in the hallway..

Restrooms: The proposed facility has three (3) full bathrooms for resident use; one half bath located at the entry. LPA observed night-lights were present in the hallways. All restrooms contained grab bars and non-skid mats. Hot water was measured at 115.3 degrees Fahrenheit.

Report Continued on LIC 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/15/2024
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: NAVITA RESIDENCES ASHWOOD
FACILITY NUMBER: 565850557
VISIT DATE: 10/15/2024
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Report Continued from LIC 809


Common Areas: 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 working telephone is present. There is one (1) fireplace in the residence, which was properly screened at the time of the visit. Chemicals are stored in a locked cabinet in the laundry room and in the locked garage. A locked medication closet is located near the entry area. First aid kit was observed to be complete. There were no bodies of water observed. Building and grounds are free from hazard. Patio area observed outdoor shaded seating area for resident use. The one (1) outdoor exit gate was observed to be self-closing and self-latching.

Kitchen: The kitchen contained a sufficient supply of dishes, glasses and utensils. A seven-day supply of non-perishable food is present and an emergency supply of water is present. Knives are stored in a locked cabinet. Hot water was measured at 118.3 degrees Fahrenheit. The refrigerator/freezer was at the appropriate temperature (40*F and 0*F).

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.

No deficiencies were observed. Exit interview conducted and a copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:

DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/15/2024
LIC809 (FAS) - (06/04)
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