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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609646
Report Date: 05/06/2025
Date Signed: 05/06/2025 12:29:34 PM

Document Has Been Signed on 05/06/2025 12:29 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 HEALTHCARE 2FACILITY NUMBER:
567609646
ADMINISTRATOR/
DIRECTOR:		TOUME, CILVAFACILITY TYPE:
740
ADDRESS:1423 DOVER AVETELEPHONE:
(805) 494-1909
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
05/06/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:45 AM
MET WITH:Cilva ToumeTIME VISIT/
INSPECTION COMPLETED:
12:45 PM
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Licensing Program Analyst (LPA) Esther Cortez conducted a subsequent case management visit to deliver findings for the death investigation initiated on 02/27/2024 case management visit. LPA met with Administrator Cilva Toume and Assistant Administrator Vana Barberis and explained the reason for the visit.

On 02/26/2024, the Department received a self-reported death report from the facility. The death report stated that on 02/20/2024, Resident #1 (R1) was seen choking on their saliva by the caregiver on duty. The caregiver immediately called 911 and began CPR. The Department referred the case to the Community Care Licensing (CCL) Investigations Branch (IB). The case was assigned to Investigator Laura Garcia to conduct the investigation.

On 02/27/2024, from 3:15pm to 6:45pm, Licensing Program Analyst (LPA) Esther Cortez conducted an unannounced Case Management – Incident visit to the above facility. LPA Cortez met with the administrator Cilva Toume and explained the reason for the visit was to follow up on the self-reported death report received on 02/26/2024. The report pertained to the 02/20/2024 death of Resident #1 (R1). During the visit, the LPA conducted interviews with staff and R1's resident representative, conducted a brief tour of the facility, and obtained copies of pertinent documents. The LPA informed the administrator that the incident was referred to the Community Care Licensing (CCL) Investigations Branch (IB) for review and further investigation was required prior to issuing findings.

Report will continue on LIC809-C, 2nd page.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/06/2025
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 2
FACILITY NUMBER: 567609646
VISIT DATE: 05/06/2025
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On 03/04/2024, at approximately 12:00pm, CCL IB Investigator Garcia conducted an interview with the administrator; on 03/07/2024, from approximately 11:45am to 2:30pm, with administrator, staff, and resident; on 04/15/2024, at approximately 12:00pm, with R & G Home Health Care Services medical staff; and on 04/25/2024, at approximately 11:35am, with R1’s physician Dr. Gehlani. In addition, Investigator Garcia requested Ventura County Sheriff’s Department and Emergency Medical Services reports. To date, no reports have been obtained.

A review of R1’s facility file documents indicate that R1 was admitted to the facility on 08/12/2022. R1’s Physician Report, dated 08/24/2023, lists diagnosis as HTN, HLD, and Hypothyroid. The report also lists Mild Cognitive Impairment (MCI), needs assistance with self-care, except for feeding, disoriented, confused, able to follow instructions and able to communicate needs.

The investigation revealed that on 02/13/2024, R1 tested positive for COVID-19. Due to the diagnosis with COVID-19, R1’s physician, prescribed a nebulizer which consisted of 15-to-20-minute treatments.
R & G Home Health Services conducted training with staff and R1 and visited R1 three times per week. It was noted in the home health notes that R1 was able to remove the nebulizer mask by their self.

On 02/20/2024, at approximately 5:30pm, facility staff indicated that while R1 was receiving the nebulizer treatment, they were in direct line of sight of R1 and as soon as they noticed R1 was having trouble breathing, they immediately dialed 911 and performed CPR until paramedics arrived on scene. The paramedics arrived and continued with CPR measures. Per the administrator, the paramedics continued CPR measures for an additional 40 minutes until R1’s passing. R1’s certificate of death from Ventura County Registrar and Recorder office noted R1’s primary cause of death, was due to cardiac arrest and hypertension. COVID-19 was also noted as a significant contributing factor to R1’s death.

During the course of the investigation, interviews were conducted with facility staff members, residents, R1’s physician Dr. Ghelani, and R & G Home Health Care Services medical staff. The home health clinical notes were also obtained and reviewed. R1’s physician and home health nurses denied observing neglect or lack of care by facility staff members. The home health agency was involved with the continuous care of R1.
Report will continue on LIC809-C,3rd page.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
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 2
FACILITY NUMBER: 567609646
VISIT DATE: 05/06/2025
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 Staff described R1 as able to express their needs, despite age-related cognitive decline. R1 had the capability of self-administering the nebulizer treatment and training had been previously provided to staff on how to assist with R1's treatment and condition. Dr. Ghelani and the home health staff confirmed that R1 did not require direct supervision or one-to-one care during treatments. R1 had last been seen by the home health nurse on 02/19/2024 and there were no signs of respiratory distress noted.

Based on the information obtained, there is insufficient evidence to support neglect/ lack of care leading to the death of R1. Therefore, the allegation is deemed Unsubstantiated at this time.

Exit interview, copy of report given.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Esther Cortez
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 05/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/06/2025
LIC809 (FAS) - (06/04)
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