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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800978
Report Date: 03/25/2022
Date Signed: 03/25/2022 10:44:38 AM


Document Has Been Signed on 03/25/2022 10:44 AM - 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:UNIVERSITY VILLAGE THOUSAND OAKSFACILITY NUMBER:
565800978
ADMINISTRATOR:DMITRY ESTRINFACILITY TYPE:
741
ADDRESS:3415 CAMPUS DRIVETELEPHONE:
(805) 241-3000
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:514CENSUS: 474DATE:
03/25/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Dmitry EstrinTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Ashley Smith conducted an unannounced case management visit today to obtain additional information surrounding an incident that occurred on 03/21/2022. The LPA met with RN Brianne Fowler and Executive Director Dmitry Estrin and explained the reason for the visit.

On 03/22/2022, the Department received an unusual incident report regarding Resident #1 (R1). It was reported that on 03/21/2022 at approximately 2:24 p.m., staff were notified that R1 was choking in the Avalon dining room. Upon arrival, R1 was observed gasping for air and the color had drained from R1's face. Staff performed the Heimlich maneuver and a call to the local fire department and emergency services was placed. At approximately 2:29 p.m. the object obstructing R1’s airways appeared to be dislodged. Thereafter, R1 began breathing and the color returned to R1’s face. R1 was seated in a chair and became combative. R1 began kicking staff and tried to push them away. The local fire department arrived on the scene at approximately 2:32 p.m. As the fire department approached the dining room, R1 became unresponsive. The local fire department immediately began CPR. At 3:11 p.m., R1 was pronounced deceased.

During today's visit, the LPA reviewed R1's file, obtained pertinent documents and interviewed staff. Per the records review, R1 did not require special dietary accommodations, did not required a pureed and/or chopped diet, and was independent of facility services.

Further investigation is required 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: 03/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/25/2022
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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