197609632-7-31-2020-29-AS-DPEA-BS2TS7-20200731145840

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609632
Report Date: 07/31/2020
Date Signed: 07/31/2020 02:58:45 PM

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:	RESERVE AT THOUSAND OAKS, THE		FACILITY NUMBER:	197609632
ADMINISTRATOR:	SPENCER, ELIZABETH		FACILITY TYPE:	740
ADDRESS:	3575 N. MOORPARK ROAD		TELEPHONE:	(805) 492-2471
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	170	CENSUS: 144	DATE:	07/31/2020
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Elizabeth Spencer		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Desaree Perera initiated Case Management - Incident visit. The purpose of this visit is to follow up on a special incident report (SIR) submitted to the department on 07/30/2020. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, todays visit was conducted via FaceTime with Executive Director (ED) Elizabeth Spencer at 2:40pm.

It was reported that on 07/29/2020, at approximately 8:40pm staff noticed Resident #1 (R1) was missing from R1 bedroom while passing out medication. A search was immediately conducted to locate R1. R1 found approx. 10 mins later outside by the emergency cul-de-sac face down on the curb. R1 complained of hip pain and ringing of the ear. 911 was contacted immediately and R1 was transported to Los Robles Hospital. On 07/30/2020, the facility was informed that R1 passed away at the hospital at approx. 12:30pm.

A telephone interview was conducted with ED at 1:15pm to obtain additional information and request documentation. During today's virtual visit, LPA conducted a tour of the physical plant at 2:42pm with ED. Prior to issuing final licensing report, it has been determined that further investigation is needed at this time.

Exit interview conducted via telephone and report was emailed for signature.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Desaree Perera	TELEPHONE: (747) 230-3888
LICENSING EVALUATOR SIGNATURE:	DATE: 07/31/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/31/2020

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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