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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800978
Report Date: 07/23/2021
Date Signed: 07/23/2021 09:14:04 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:UNIVERSITY VILLAGE THOUSAND OAKSFACILITY NUMBER:
565800978
ADMINISTRATOR:ESTRIN DMITRYFACILITY TYPE:
741
ADDRESS:3415 CAMPUS DRIVETELEPHONE:
(805) 241-3000
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:514CENSUS: 470DATE:
07/23/2021
TYPE OF VISIT:Case Management - OtherUNANNOUNCEDTIME BEGAN:
08:00 AM
MET WITH:Dmitry EstrinTIME COMPLETED:
08:30 AM
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Licensing Program Analyst (LPA) Ashley Smith arrived at 8am to meet with Executive Director Dmitry Estrin for a technical support visit with this facility. In attendance included Public Health Nurse Amanda Ball from Ventura County Public Health. The purpose of the visit had a specific emphasis on infection control practices.

Upon entry into the campus, the campus has a central entry point for signing in, symptom screening, and temperature checks. The campus has appropriate signs in the common spaces to promote proper hand hygiene, physical distancing, and symptom reporting. Staff and residents were observed wearing masks throughout the common spaces. Hand sanitizer was available throughout the common spaces for resident and staff use.

During today's visit, discussion was had regarding the current status of positive residents and staff, testing, communication to staff and families, symptom screening, and adjusted procedures around visitation and excursions. The community is not experiencing any issues with staffing or obtaining Personal Protection Equipment (PPE) at this time. Cleaning and disinfectant protocol is adequate.

No health and safety hazards noted during today's visit. Exit interview conducted. A copy of the report was emailed for signature.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:

DATE: 07/23/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2021
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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