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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800978
Report Date: 10/20/2023
Date Signed: 10/20/2023 10:47:10 AM


Document Has Been Signed on 10/20/2023 10:47 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
WOODLAND HILLS N.ASC, 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: 471DATE:
10/20/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
08:56 AM
MET WITH:Dmitry Estrin TIME COMPLETED:
11:00 AM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 8:56 a.m., the LPA met with staff and explained the reason for the visit. At 9:28 a.m., Executive Director (ED) Dmitry Estrin arrived at the facility.

The reason for today's inspection is to follow up on a self-reported report received on 10/18/2023. The report pertains to the death of Residen#1 (R1). The cause of death is currently unknown. At 9:32 a.m., an interview was conducted with the ED. At 10:06 a.m., the LPA, along with the ED conducted a brief tour of the facility. During the time of the visit, the LPA obtained copies of pertinent documents. At 10:20 a.m., an interview was conducted with the Director of Resident Health Services Brianne Knight.

No immediate health and safety concerns were observed during today's inspection. An additional report may follow if warranted.

Exit interview conducted and report reviewed with the ED. A copy of the report was provided.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 10/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/20/2023
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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