565800978-7-26-2024-29-AS-KDUK-D7K2XR-20240726174733

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800978
Report Date: 07/26/2024
Date Signed: 07/26/2024 05:47:45 PM

Document Has Been Signed on 07/26/2024 05:47 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:	UNIVERSITY VILLAGE THOUSAND OAKS		FACILITY NUMBER:	565800978
ADMINISTRATOR:	DMITRY ESTRIN		FACILITY TYPE:	741
ADDRESS:	3415 CAMPUS DRIVE		TELEPHONE:	(805) 241-3000
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	514	CENSUS: 471	DATE:	07/26/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:55 AM
MET WITH:	Dmitry Estrin, Executive Director		TIME COMPLETED:	05:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived unannounced to conduct a required annual visit. Upon arrival, LPA was greeted by front desk staff. At 10:05AM, LPA met with Executive Director (ED) Dmitry Estrin and explained the reason for the visit. Entrance interview conducted.

At 10:30AM, LPA along with the ED, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers throughout the community were observed to be fully charged and recently serviced 04/19/2024. Annual fire safety/sprinkler system was tested on 03/26/2024 by Service Pro Fire Protection; all systems passed at that time. 5-year inspection was conducted on 03/17/2023 and all systems passed.

COMMON GROUNDS: This community is in an Independent Living section of the Continuing Care Retirement Community (CCRC). The facility is a gate-guarded community with 24-hour security. There are 4 main buildings: Lakeview, Creekview, Mountainview and Gardenview.

The Clubhouse has a commercial kitchen, dining rooms, activity rooms, business office, and library. The community also has a fitness center and a pool. Planned activities are offered. The activity schedule is posted throughout the community. LPA observed residents engaging in various group activities. All activity rooms and common spaces appeared clean and in good repair. LPA observed required postings located in the mailroom.

RESIDENT UNITS: LPA observed 21 (twenty one) various resident living units throughout the 4 (four) main buildings and villas. All resident units observed contain a kitchen, living area, bedroom(s) and private restroom(s). All units observed were in good repair, with clean linens, proper furnishings and adequate Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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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Document Has Been Signed on 07/26/2024 05:47 PM - It Cannot Be Edited

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: UNIVERSITY VILLAGE THOUSAND OAKS	FACILITY NUMBER: 565800978
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/26/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87208(a)

Plan of Operation

(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above, as the facility's Admission Agreement indicates that the licensee may transfer a resident from Independent Living if there are statutory or other grounds for a transfer, however R1 has a diagnosis of dementia and was observed in an Independent Living unit and has not been transferred per the facility's plan of operation which poses a potential health & safety risk to persons in care.
	POC Due Date: 08/09/2024
	Plan of Correction
1 2 3 4	Executive Director agreed to submit a plan in writing to address compliance with the facility's Plan of Operation. This plan will be submitted to CCL by POC due date.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

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: UNIVERSITY VILLAGE THOUSAND OAKS	FACILITY NUMBER: 565800978
	VISIT DATE: 07/26/2024

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lighting. Water temperature was measured in various resident sinks and measured between 116.2 degrees F to 118.6 degrees F, which is within the required range.

EXTERIOR GROUNDS: LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Parking is available for residents and visitors. The exterior and interior grounds were free of clutter and/or obstructions. The community has a swimming pool and a spa, both of which are appropriately fenced with self-locking gates. There is a pond and environmentally protected land, which includes a riparian; both pond and open space are not fenced.

RECORD REVIEW: Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All 10 (ten) resident files and all 10 (ten) staff files observed contained all required documents. Review of records for Resident #1 (R1) revealed that R1 has a diagnosis of dementia and requires assistance with ADL care, including medications and additional supervision. R1 was observed to be residing in a villa in independent living.

MEDICATION REVIEW: Medications were observed to be stored in a locked Medication Room. Medications for 3 (three) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

KiTCHEN: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food and water at the time of the visit, stored in a storage unit in the Mountainview building. The menu was posted and the facility offers an alternate menu. Continental breakfast, snacks and beverages are available for residents.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted monthly, with the last drill conducted 06/30/2024.

INTERVIEWS: LPA spoke with 14 (fourteen) residents during the tour; residents were very satisfied and voiced no concerns. LPA interviewed 5 (five) staff. No concerns were noted.

Pursuant to Title 22 CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Executive Director was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 07/26/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/26/2024

LIC809 (FAS) - (06/04)

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