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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801460
Report Date: 11/09/2022
Date Signed: 11/09/2022 02:47:16 PM


Document Has Been Signed on 11/09/2022 02:47 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:OMNICARE IIFACILITY NUMBER:
565801460
ADMINISTRATOR:JOSEPH JOSEFACILITY TYPE:
740
ADDRESS:154 THAMES STREETTELEPHONE:
(805) 777-8143
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 5DATE:
11/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Laila KulunguTIME COMPLETED:
02:00 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. The LPA met with staff Laila Kulungu and explained the reason for the visit. The LPA toured the facility to ensure there are no health and safety hazards and to ensure regulatory compliance.

KITCHEN: Knives and chemicals were locked inaccessible. Appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The rooms were furnished appropriately; beds had clean linens and rooms had sufficient lighting. All direct exits were clear and no obstructions were noted. RESTROOMS: Restrooms were clean and sanitary with grab bars and non-skid surfaces. At 1:10 p.m., water temperature measured at 108.2 F. Restrooms were fully stocked. Hand-washing signs were observed. COMMON SPACES: Living room and dining room furniture were observed to be in good condition. There was a fire place, which was covered and inaccessible. Smoke detectors and carbon monoxide detectors were tested at 1:20 p.m. and were operational at the time of the visit. Fire extinguishers were fully charged and serviced 8/2022. All exits have functioning auditory devices. The backyard had furniture and a covered area for resident use. The garage is attached to the house but is kept locked. The washer and dryer, PPE supplies, and cleaning supplies are in the garage. There was an in-ground pool, which was appropriately fenced and locked at the time of the visit. The side gate door was self-latching.

INFECTION CONTROL: There was a central entry point for symptom screening and temperature checks. The LPA was appropriately screened upon entry into the facility. Staff were wearing appropriate face coverings. Infection Control signs were observed on the front door and throughout the facility. Facility has a sufficient supply of PPE. The facility’s cleaning protocol is sufficient. There was record of staff and resident vaccinations. The LPA discussed changes around testing, visitation and vaccine requirements. The facility's procedures as it pertains to infection control are adequate.

No deficiencies cited 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: 11/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/09/2022
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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