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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561704040
Report Date: 02/25/2022
Date Signed: 02/25/2022 12:45:51 PM

Document Has Been Signed on 02/25/2022 12:45 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:SENIOR CONCERNS ADULT DAY SUPPORT CENTERFACILITY NUMBER:
561704040
ADMINISTRATOR:ANDREA GALLAGHERFACILITY TYPE:
775
ADDRESS:401 HODENCAMP RDTELEPHONE:
(805) 497-0189
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 75CENSUS: 11DATE:
02/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:40 AM
MET WITH:Martha ShapiroTIME COMPLETED:
12:50 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit at 11:40 a.m. This annual had an emphasis on infection control practices and procedures. The LPA met with Program Director Martha Shapiro and explained the reason for the visit. There are 11consumers and 4 program staff in program today. The Day Program currently operates from 10:00 a.m. to 2:00 p.m.

The LPA toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Activity Space: The facility is a single-story structure with several activity rooms (Discovery and Harmony), common bathrooms, office spaces, and conference rooms. The LPA did not observe any obstructions or hazards. Equipment used for activities was in good condition at the time of the visit. In addition, the facility has a covered outdoor space equipped with furniture for consumer use.

Activities: The program offers both individual and group activities. The program has designated materials for each consumer. The LPA observed staff actively working and engaging with consumers. The LPA observed that consumers were seated at least six feet apart. At the time of the visit, staff were observed wearing surgical masks.

Food Service: The program serves lunch and two snacks. A registered dietitian oversees the food program. The program is able to manage and meet all dietary restrictions of the consumers as needed. The LPA observed that staff whom assisted with the preparation and delivery of meals wearing the appropriate Personal Protection Equipment (PPE).

CONT 809-C
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE: DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/25/2022
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: SENIOR CONCERNS ADULT DAY SUPPORT CENTER
FACILITY NUMBER: 561704040
VISIT DATE: 02/25/2022
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Restrooms: Restrooms were clean and sanitary and trash cans have lids to protect consumers from cross contamination. The LPA observed appropriate signs promoting good hand hygiene. The restrooms were fully stocked with soap and paper towels.

Infection Control: During today’s visit, the LPA spoke with the Program Director regarding the program’s infection control practices. Upon entry into the building, the program has a central entry point for symptom screening, temperature checks, and sanitation station. The program maintains records of daily temperature checks. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the program is able to obtain additional supplies as needed. The LPA observed hand sanitizer throughout the space for consumer and staff use. This program has documented records of staff vaccinations. The LPA observed appropriate signage throughout the space that promoted good hand hygiene, signs and symptoms of COVID-19, and proper mask usage. The program's cleaning protocol is sufficient. The emergency contact information for all consumers is up-to-date and readily available. If need be, the program has the capacity to isolate a consumer if they exhibit any symptoms of COVID-19 during program. The program's policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited at this time. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:

DATE: 02/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/25/2022
LIC809 (FAS) - (06/04)
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