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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801812
Report Date: 09/23/2022
Date Signed: 09/23/2022 03:13:54 PM

Document Has Been Signed on 09/23/2022 03:13 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:COMPASSIONATE CARE RESIDENCEFACILITY NUMBER:
565801812
ADMINISTRATOR:DAVID FLOODFACILITY TYPE:
740
ADDRESS:1595 KIRK AVENUETELEPHONE:
(805) 870-4789
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
09/23/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:30 PM
MET WITH:David & Kathie FloodTIME COMPLETED:
03:15 PM
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Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced visit to the facility above to conduct a Required 1-Year Annual Inspection with focus on Infection Control. The last annual conducted at this facility was on 8/18/2019. The LPA was greeted and screened at the door by staff, Marissa. The Administrator, Kathie Flood arrived shortly after and the reason for the visit was explained. Entrance interview.

At 2:00 p.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed three (3) locked drawers designated for knives and sharps. Medications were observed in a locked cabinet inside the office.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. Bathrooms were measured for hot water and measured between 105- and 120-degrees Fahrenheit.

…Report Continued on LIC 809C…

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/23/2022
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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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: COMPASSIONATE CARE RESIDENCE
FACILITY NUMBER: 565801812
VISIT DATE: 09/23/2022
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…Report Continued from LIC 809...

BACKYARD AND GROUNDS: Cleaning supplies and chemicals are locked and inaccessible to residents. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. The LPA observed no bodies of water during time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed all six (6) residents in the living room during time of visit. Fire extinguisher was observed to be purchased on 7/17/2022.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, and CDSS PINS. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff are fully vaccinated and boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Exit interview conducted. No citations issued. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 09/23/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2022
LIC809 (FAS) - (06/04)
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