565800711-7-21-2021-29-AS-SURA-C55PXP-20210721114241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800711
Report Date: 07/21/2021
Date Signed: 07/21/2021 11:44:21 AM

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:	THOUSAND OAKS HOME CARE IV		FACILITY NUMBER:	565800711
ADMINISTRATOR:	JOVY SARREAL		FACILITY TYPE:	740
ADDRESS:	254 E. SIDLEE ST.		TELEPHONE:	(805) 494-8860
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	07/21/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jovy Sarreal		TIME COMPLETED:	12:00 PM

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On 07/21/2021 at 9:00 am, Licensing Program Analyst (LPA) Sandra Urena arrived to facility, introduced herself and explained the reason for the visit. LPA conducted an unannounced required annual inspection visit. Administrator called licensee to be present during the visit. Licensee explained that facility is in the process of change of ownership.

INFECTION CONTROL: Upon entry, the facility has a sign in book, thermometer to take temperature and sanitizing gel. Infection Control signage was visible at entrance.

At 9:30 am LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Bedrooms: At 9:30 am, LPA observed the residents’ bedrooms. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Each bedroom has a sliding glass door which opens to the patio area. Doors are equipped with sound systems to alert caregivers if residents open sliding doors. Bedrooms are single occupancy.

Bathrooms: At 9:40 am, LPA observed the Residents’ restrooms. Restrooms were clean, shower area was in clean condition with grab bars and non-skid mat available. Paper towels were available for drying hands.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

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: THOUSAND OAKS HOME CARE IV	FACILITY NUMBER: 565800711
	VISIT DATE: 07/21/2021

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Kitchen: At 10:00am, LPA observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff.

Outdoor Space: At 10:15 am, LPA observed the Outdoor space. A shaded patio is available for residents to visit with family members. Side gates are unlocked. Emergency water and food supplies are stored in the garage area.

Facility Records: At 10:45 am LPA reviewed staff and residents’ records. All flies are in good order, and meet

requirements.

At 11:10 am LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were cited at this time. Exit interview conducted. Signatures obtained. A copy of report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 07/21/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/21/2021

LIC809 (FAS) - (06/04)

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