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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609632
Report Date: 04/23/2024
Date Signed: 04/23/2024 12:24:49 PM


Document Has Been Signed on 04/23/2024 12:24 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: 141DATE:
04/23/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:10 AM
MET WITH:Elizabeth SpencerTIME COMPLETED:
12:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced Case Management – Incident visit for the purpose of following up on a self-reported incident that occurred on 04/08/2024. Upon arrival, LPA was greeted by front desk staff, Lyn. LPA met with Business Office Manager Miguel Lino and explained the reason for today's visit. Executive Director (ED) Elizabeth Spencer arrived shortly after the visit began.

On 04/18/2024, LPA Dulek received a voicemail from ED Spencer asking for a call back related to an incident that had occurred at the facility. LPA and ED spoke over the phone on 04/19/2024. During the telephone conversation, ED explained that there had been an incident on 04/08/2024 involving Resident #1 (R1). Another resident had backed up their scooter while R1 was ambulating using their walker, causing R1 to fall and hit their head. R1 was hospitalized following the incident and ED was made aware by R1's family that R1 had passed away at the hospital. Written incident report and death report were faxed to the Regional Office on 04/19/2024.

During today's visit, LPA interviewed ED related to the incident and LPA, along with ED, toured the pertinent areas of the facility at 10:40AM. No immediate health and safety hazards were identified during today’s visit. LPA also reviewed R1's file and obtained copies of pertinent documents, and interviewed staff from 11:34AM to 12:00PM.

LPA may return at a later date if further investigation is needed.

No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 04/23/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/23/2024
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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