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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609632
Report Date: 05/26/2022
Date Signed: 05/26/2022 09:34:40 AM


Document Has Been Signed on 05/26/2022 09:34 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:RESERVE AT THOUSAND OAKS, THEFACILITY NUMBER:
197609632
ADMINISTRATOR:SPENCER, ELIZABETHFACILITY TYPE:
740
ADDRESS:3575 N. MOORPARK ROADTELEPHONE:
(805) 492-2471
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:170CENSUS: 150DATE:
05/26/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:45 AM
MET WITH:Prisila BustosTIME COMPLETED:
09:35 AM
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced Case Management - Incident visit. The LPA met with Assisted Living Director Prisila Bustos and explained the reason for the visit. Executive Director Elizabeth Spencer was out of the community at the time of the visit.

On 5/25/2022, the facility submitted a Report of Suspected Dependent Adult/Elder Abuse and a Special Incident Report regarding an alleged violation of personal rights against Resident #1 (R1). This incident was also cross reported to the local ombudsman office and the local police department.

During today's visit, the LPA obtained documents. It is noted that this incident was referred to Community Care Licensing Investigation's Branch (IB) and assigned to Investigator Edward Hector. Further investigation is required before findings are delivered.

No health and safety hazards noted at this time, and no citations were issued.



Exit interview conducted. A copy of the report was issued. A copy of the signed report was emailed to Executive Director Elizabeth Spencer.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 05/26/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/26/2022
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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