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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609632
Report Date: 07/12/2023
Date Signed: 07/12/2023 04:52:04 PM


Document Has Been Signed on 07/12/2023 04:52 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: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: 127DATE:
07/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Elizabeth SpencerTIME COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. The LPA met with Executive Director Elizabeth Spencer and informed them of the reason for the visit.

At 9:55 a.m., the LPA and the Executive Director toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

Common Areas: The facility is a three-story building. There are resident rooms on all three floors, units are designated for assisted living residents on all three floors. In addition, there are additional resident units in six (6) stand-alone buildings.

Common spaces on the first floor include the theater, salon, secured pool, and spa. The second floor includes the reception area/lobby, library, activity rooms, fitness room, and physical therapy room. The third floor includes the kitchen/dining services, and activity rooms. There were no obstructions and/or tripping hazards throughout the facility. There are fire extinguishers throughout the facility, which were charged and last serviced 8/2022. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair.

Kitchen: Dining is located on the third floor and was observed to be clean and sanitary. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. The menu was posted, and the facility offers daily specials and a standard selection at every meal. Snacks and beverages are available for residents in the Bistro area on the 2nd floor.

Resident Units: The LPA and Executive Director toured thirteen (13) randomly selected resident units throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting. Smoke detectors observed in resident units were operational at the time of the visit.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
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: RESERVE AT THOUSAND OAKS, THE
FACILITY NUMBER: 197609632
VISIT DATE: 07/12/2023
NARRATIVE
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Restrooms: The LPA and Executive Director observed restrooms in thirteen (13) resident units. All restrooms were fully stocked with supplies. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces in the bathing unit. Water temperature was tested throughout the visit, and water measured between 110 – 120 degrees Fahrenheit.

Outside areas: The LPA and Executive Director toured the outside areas and courtyards. There was appropriate outdoor furniture, with a covered shaded area for residents observed in several facility courtyards. There is a locked pool for resident usage with appropriate fencing and it was locked inaccessible. For residents to use the pool, residents must check out a key from the front desk. Parking is available for residents and visitors.

Files: Residents records review began at 11:50 a.m. Six (6) records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. Resident records were in order.

Six (6) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training. Out of the six (6) files reviewed, three (3) require valid first aid certification (Staff #1, Staff #2, Staff #3). Otherwise, records were in order. Facility conducts emergency drills regularly. Training records were reviewed, and no discrepancies were observed at the time of the visit.

Medications: Medications review began at 2:30 p.m., Medications are centrally stored and locked in the Wellness Center on the third floor. For one resident (R1), the pill count was off for two medications (Xarelto, Escitalopram) by one pill, specifically for 7/10/2023. Staff checked R1's medical record (MAR) but it was indicated as administered on 7/10/2023. Not all medications were documented on the centrally stored medications and destruction record (CSMDR) for 4 out of 5 residents (R1, R2, R3, R4). However, staff re-requested the CSMDR forms from the pharmacy during today's visit. Technical violation issued.

Documentation: The LPA obtained a copy of the liability insurance, Infection Control Plan, resident roster, and staff roster.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):


Exit interview conducted. A copy of the report and appeal rights were issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2023
LIC809 (FAS) - (06/04)
Page: 2 of 5
Document Has Been Signed on 07/12/2023 04:52 PM - It Cannot Be Edited

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: RESERVE AT THOUSAND OAKS, THE
FACILITY NUMBER: 197609632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87465(a)(4)
87465(a)(4) Incidental Medical and Dental Care. The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on the medication audit, the licensee did not comply with the section cited above, as the medication count was off for 1 out of 5 residents (R1), which poses an immediate health and safety risk to residents in care.
POC Due Date: 07/14/2023
Plan of Correction
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The Administrator agreed to do the following:
1. Conduct a medication audit with medication technicians, ensuring that staff are up-to-date regarding medication administration procedures. Training must begin within the next 48 hours, to be completed by 7/21/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
LIC809 (FAS) - (06/04)
Page: 3 of 5


Document Has Been Signed on 07/12/2023 04:52 PM - It Cannot Be Edited

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: RESERVE AT THOUSAND OAKS, THE
FACILITY NUMBER: 197609632

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/12/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(c)(1)
87411(c)(1) Personnel Requirements – General. Staff providing care shall receive appropriate training in first aid from persons qualified by such agencies as the American Red Cross.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in 3 out of 6 staff files (S1, S2, S3), which poses a potential health and safety risk to residents in care.
POC Due Date: 07/21/2023
Plan of Correction
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The Administrator has agreed to do the following:
1. Obtain valid first aid certification for the three staff no later than 7/21/2023
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2023
LIC809 (FAS) - (06/04)
Page: 5 of 5