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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609632
Report Date: 06/24/2022
Date Signed: 06/24/2022 02:40:09 PM


Document Has Been Signed on 06/24/2022 02:40 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: 150DATE:
06/24/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:35 PM
MET WITH:Elizabeth SpencerTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Executive Director Elizabeth Spencer and informed them of the reason for the visit.

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. Upon entry to the facility, there is a central entry point for symptom screening and temperature checks for residents, staff, and visitors. Staff were observed wearing appropriate face coverings throughout the visit. In addition, the LPA observed hands-free hand sanitizer interspersed throughout the common grounds.

There were no obstructions or tripping hazards throughout the facility. The facility maintains a comfortable temperature at 73 degrees. 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.

Outside areas: The LPA toured the outside area of the facility and the courtyard. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. There is a pool for resident usage with appropriate fencing and it was locked at the time of the visit.. Parking is available for residents and visitors. Area is maintained clean.

Kitchen: Dining is located on the third floor and was observed to be clean and sanitary at the time of the visit. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food at the time of the visit. The menu was posted and the facility offers an alternate menu. Facility uses Sysco Foods for food deliveries, and delivery takes place twice a week. Snacks and beverages are available for residents in the Bistro area on the 2nd floor.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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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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: 06/24/2022
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Common Restrooms: The LPA observed common restrooms on all three floors. The LPA informed the Executive Director that signs promoting good hand hygiene should be placed in all common restrooms in the facility. However, all restrooms were fully stocked with soap and paper towels.

Infection Control: During today’s visit, the LPA spoke with the Executive Director regarding the community's infection control practices. The LPA encouraged the Executive Director to create a centralized location with COVID-19 signage that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. However, the community previously had the appropriate signs posted for resident review prior to the cosmetic changes made on the second floor. The community has an adequate supply of Personal Protection Equipment (PPE) and is able to obtain additional supplies. The community's cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. If needed, the facility has the capacity to designate isolation zones or can isolate persons in their room if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines pertaining to visitation and vaccine requirements. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The Infection Control Plan was submitted timely. The community's policies and procedures pertaining to infection control were adequate.

No deficiencies observed at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/24/2022
LIC809 (FAS) - (06/04)
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