405800577-7-30-2024-29-AS-MRAN-D7P2FT-20240730172204

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 07/30/2024
Date Signed: 07/30/2024 05:22:12 PM

Document Has Been Signed on 07/30/2024 05:22 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	VILLAGE AT SYDNEY CREEK, THE		FACILITY NUMBER:	405800577
ADMINISTRATOR:	LIZA HIX		FACILITY TYPE:	740
ADDRESS:	1234 LAUREL LANE		TELEPHONE:	(805) 543-2350
CITY:	SAN LUIS OBISPO	STATE: CA	ZIP CODE:	93401
CAPACITY:	84	CENSUS: 60	DATE:	07/30/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Liza Hix, Administrator		TIME COMPLETED:	05:45 PM

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On 7/30/24 at 9:03 am, Licensing Program Analyst (LPA) Rankin made an unannounced Annual/Required visit to the facility above. LPA met with Liza Hix, Administrator, and explained the purpose of the visit.

Physical Plan tour was done, and the following was noted: LPA observed the license posted, Complaint Poster, Bill of Rights and Right to Residential Council, non-discrimination statement, and resident rights.
The facility conducted Emergency Disaster Drills quarterly as required.

The facility maintains a comfortable temperature. The smoke detectors are hard wired and carbon monoxide detectors are placed in each neighborhood, this is reviewed annually by an outside service. Fire extinguishers are located throughout the facility, they were inspected in 04/2024 and are charged in the green.

Living rooms, dining rooms, and activity room furniture were checked and in good condition. The common rooms are clean, safe and sanitary.

The courtyards of the facility have outdoor furniture, with shaded area for residents.

The kitchen area was sufficiently stocked with two-day perishable and seven-day non-perishables. The menu was posted for review. Snacks and beverages are available for residents in the facility when they want. Foods are properly wrapped and stored appropriately. Food storage and preparation areas are clean and inaccessible to pests.

Continued on 809-C

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: VILLAGE AT SYDNEY CREEK, THE	FACILITY NUMBER: 405800577
	VISIT DATE: 07/30/2024

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Resident rooms are adequately supplied with sheets, pillowcase, mattress pad, and blankets which are in good condition. There is at least one chair, night stand, and sufficient lighting for each resident. There is enough linen available to change weekly or more, if needed.

Activity Room has sufficient activities for residents to stay active. Planned activities are offered to residents in care. There is staff hired to coordinate the activities and an activity calendar was available and reviewed.

The bathrooms were checked for cleanliness and proper operation. Secured grab bars were noted, sufficient supplies for hand washing was observed.

Resident records were reviewed for requirements and legibility: LPA reviewed 5 residents’ files for Medical Assessments, Needs and Service plans, Signed Admission Agreements and Pre-appraisals. There were no issues with resident files reviewed.

Medications are centrally stored in a locked medication room. Medications labels from pharmacy are correctly labeled and not tampered with, and a check for expiration dates was done. Updated training is schedule and LPA will follow up and review a sampling of medication on final inspection.

Exit interview conducted, and the report printed and given to administrators.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa Rankin	TELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:	DATE: 07/30/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/30/2024

LIC809 (FAS) - (06/04)

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