197609562-4-10-2024-29-AS-ZCHN-D485DA-20240410195137

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609562
Report Date: 04/10/2024
Date Signed: 04/10/2024 07:51:57 PM

Document Has Been Signed on 04/10/2024 07:51 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:	APPLEGATE @ SIRIUS		FACILITY NUMBER:	197609562
ADMINISTRATOR:	ALVAREZ, CYNTHIA		FACILITY TYPE:	740
ADDRESS:	2614 SIRIUS STREET		TELEPHONE:	(805) 380-9400
CITY:	THOUSANDS OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	04/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:30 AM
MET WITH:	Cynthia Alvarez and Emma Carmona		TIME COMPLETED:	03:30 PM

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Licensing Program Analyst (LPA), Zabel Chochian conducted an annual required visit to this facility today. The LPA was greeted by staff upon arrival. One of the Administrators, Emma Carmona arrived shortly after. Reason for the visit was explained. Administrator Cynthia Alvarez also joined the visit.

At approximately 11:45 am., the LPA began the physical plant tour with Administrator Emma Carmona. The common areas, kitchen area, resident bedrooms, bathrooms, and outdoor areas were toured to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives and chemicals are locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The six single-occupancy resident rooms were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear and no obstructions were noted. RESTROOMS: Each resident room has a restroom and there is one common restroom in the hallway. Restrooms were clean and sanitary with grab bars and non-skid surfaces. Hot water temperature measured between 112.5 to 118.6 F. Restrooms were fully stocked with hand soap, paper towels and toilet paper. COMMON SPACES: The LPA observed the living room area which was observed to be clean and properly furnished with for resident use. Smoke detectors and common monoxide detectors were tested and operable at the time of the visit. Fire extinguishers were fully charged and serviced 3/19/2024. All exits have functioning auditory devices. The backyard had furniture and a covered patio set for resident use. The side gate door was self-latching. No bodies of water noted. GARAGE AND GROUNDS: The garage is locked and attached to the house. There is one (1) additional refrigerator and freezer in the garage with perishable items in good condition. Garage contains a laundry area, extra food supplies, personal protection equipment and incontinence supplies.

RECORDS: Residents’ records were reviewed from approximately 12-1pm, for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. (Continue to LIC809C.)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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: APPLEGATE @ SIRIUS	FACILITY NUMBER: 197609562
	VISIT DATE: 04/10/2024

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Staff records review began at approximately 1pm, records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and all other required training. All staff files were in order. Training records observed were missing the duration/time of training and missing staff signatures. Discussion was held regarding training record keeping and Administrators and Licensee acknowledged understanding of the requirements.

MEDICATIONS: Medications review began at 2pm; medications are centrally stored and locked in a closet in the kitchen to the right of refrigerator. Medications are labeled and checked for expiration dates, prescription numbers and date filled. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

Following documents requested to be sent to the Regional office:

- Current/updated LIC 500
- Current/updated LIC 308
- Liability Insurance

No deficiencies cited at this time. Exit interview conducted. A copy of the report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC809 (FAS) - (06/04)

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