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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609632
Report Date: 07/16/2024
Date Signed: 07/16/2024 05:33:05 PM


Document Has Been Signed on 07/16/2024 05:33 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: 142DATE:
07/16/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:08 AM
MET WITH:Edward (Eddie) OceguedaTIME COMPLETED:
05:40 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a required annual visit. The LPA met with Associate Executive Director (AED) Edward (Eddie) Ocegueda and informed them of the reason for the visit. LPA was informed Executive Director is unavailable today.

At 10:45AM, the LPA and the Associate 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. The following was observed:

Fire extinguishers throughout the facility buildings were observed to be fully charged and last serviced 08/07/2023. The facility's fire safety system 5-year inspection was conducted on 12/06/2019 by Fraker Fire Protection; all relevant systems passed at that time. The annual inspection was conducted by Fraker Fire Protection on 05/23/2024, noting one area of concern in building G. Proof of repair will be provided to LPA during annual continuation.

Common Areas: The main facility structure 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. At 12:22PM, the doors to the fitness room were observed to be propped open with no staff present; 2 pairs of scissors and 2 screwdrivers were observed accessible on top of a desk. At 12:26PM, the ceiling over an open common area in the second floor was observed to be covered in plastic and dripping water. AED indicated there had been a leak in the third floor kitchen and the leak has since

Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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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Document Has Been Signed on 07/16/2024 05:33 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: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation], the licensee did not comply with the section cited above as water in room F7 measured at 138.4 degrees F and water in E1 measured at 133.1 degrees F, which poses an immediate safety risk to persons in care.
POC Due Date: 07/16/2024
Plan of Correction
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During today's visit, water was adjusted in both resident rooms. Maintenance informed LPA that each individual unit has their own water heater and that random water temperature inspections occur monthly. LPA advised to inspect units more regularly to ensure water temperature remains within the appropriate range.
Section Cited
Maintenance and Operation
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2024 05:33 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: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above as the ceiling in the main building second floor common area was covered in plastic and observed to be leaking water and has been for about a month, which poses a potential health and safety risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Associate Executive Director indicated that the area is pending repair at this time. Management will provide plan for repair by 07/23/2024 and subsequent proof of repair to CCL upon completion.
Type B
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as fruit/drain flies were observed in both the kitchen and in the server station just outside the kitchen, which poses a potential health and personal rights risk to persons in care.
POC Due Date: 07/23/2024
Plan of Correction
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Associate Executive Director indicated that pest control will be coming out on Friday to address the situation. Management will provide proof to CCL by POC due date of pest control service.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/16/2024 05:33 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: 07/16/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the Fitness Room in the main building was observed to be unlocked and unattended and contained accessible scissors and screwdrivers, laundry detergent was left unattended in the laundry room, as well as an additional staff office was left unattended and contained staff's persoal items, personal care items and COVID tests, which poses a potential safety risk to persons in care.
POC Due Date: 07/30/2024
Plan of Correction
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Doors to the Fitness Room were closed, laundry detergent was returned to the resident it belonged to, and the staff returned to the room. Relevant staff training will be conducted and proof sent to CCL by POC due date.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 07/16/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/16/2024
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: 07/16/2024
NARRATIVE
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been resolved, however, repairs on the ceiling have not been completed to date. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities.

Kitchen: Dining room is located on the third floor and was observed to be clean and sanitary. At 03:45PM, LPA observed a small fruit/drain fly in the kitchen area and immediately outside the kitchen, in the server station near the juice dispenser, LPA observed a large number of small flies, both flying about and on the ceiling. 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 Associate Executive Director toured 14 (fourteen) randomly selected resident units throughout the community. Rooms were furnished with clean linens, appropriate furniture and sufficient lighting.

Restrooms: The LPA and Associate Executive Director observed restrooms in 14 (fourteen) 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 measured at 138.4 degrees F at 11:42AM in room F7 and 133.1 degrees F at 11:49AM in room E1.

Outside areas: The LPA and Associate 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. Parking is available for residents and visitors.

Files: Residents records review began at 02:30PM, 10 (ten) records were reviewed for, but not limited to: care plans, medical records, admissions agreement, consent forms. Resident records were in order. Personnel records will be reviewed during Annual Continuation Visit.

Interviews: LPA interviewed 6 (six) residents during today's visit. LPA will conduct staff interviews during the Annual Continuation visit.

Medications: Medications will be reviewed during Annual Continuation Visit

Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
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: 07/16/2024
NARRATIVE
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Infection Control Plan/Emergency Disaster Plan: Infection control plan was not provided today and will be reviewed during Annual Continuation visit. LPA reviewed the facility's Emergency Disaster Plan, which was recently updated, however, the facility is utilizing an outdated form. LPA will email the updated form. Disaster drills are conducted weekly, with the last documented drill conducted on 07/08/2024.

Documentation: The LPA obtained a copy of the facility's liability insurance, 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 reviewed and provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 07/16/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/16/2024
LIC809 (FAS) - (06/04)
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