565801812-9-12-2024-29-AS-KDUK-D92U29-20240912151135

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801812
Report Date: 09/12/2024
Date Signed: 09/12/2024 03:11:41 PM

Document Has Been Signed on 09/12/2024 03:11 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 RESIDENCE		FACILITY NUMBER:	565801812
ADMINISTRATOR:	DAVID FLOOD		FACILITY TYPE:	740
ADDRESS:	1595 KIRK AVENUE		TELEPHONE:	(805) 870-4789
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	09/12/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:41 AM
MET WITH:	David and Kathie Flood		TIME COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required
annual visit at 11:41AM. The LPA was greeted by staff and informed them of the reason for the visit.
Administrator David Flood and co-Administrator Kathie Flood arrived shortly thereafter.

Beginning at 12:12PM, the LPA and Administrators toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

BEDROOMS/RESTROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six (6) designated resident rooms and one (1) staff break room. There are 3 (three) resident bathrooms; 2 (two) are private bathrooms and 1 (one) is a shared restroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. All restrooms were sufficiently stocked with soap and paper towels. Hot water was tested in the common restroom and measured within the required range.

COMMON AREAS: At the time of the visit, living room, family room, and dining room furniture was observed to be in good condition. There are 2 fireplaces - one in the living room and one in the family room, which were both screened and inaccessible. The facility maintained a comfortable temperature throughout the visit. Hardwired combination smoke and carbon monoxide detectors as well as fire doors were tested at 02:33PM and were operational at the time of the visit. The fire extinguisher was fully charged and purchased on 08/17/2024. The LPA observed required postings on the dining room wall.

KITCHEN: The LPA observed the facility kitchen. Knives are stored inaccessible. Cleaning supplies are stored inaccessible in the attached garage. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

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: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

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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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: 09/12/2024

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OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There is a side gate for emergency exit use and is single latched. No bodies of water noted and exits are free of obstructions. The attached garage is where the washer and dryer are held. There was a linen closet with extra towels and linens. Cleaning supplies and disinfectants are kept in locked in the garage. The LPA observed additional non-perishable food supply, emergency water, additional Personal Protection Equipment (PPE) and supplies.

RECORDS: Records review began at 01:00PM. Resident records were reviewed for, but not limited to care plans, physician's report, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first

aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 01:58PM; medications are centrally stored and kept locked in a cabinet in the office. Medications were observed for 2 (two) residents. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. The facility's procedures as it pertains to infection control are adequate. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 08/19/2024.

INTERVIEWS: During today's visit, LPA interviewed 1 (one) resident and 3 (three) staff. No concerns were noted.

The LPA obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Resident Roster
- Liability Insurance

No deficiencies cited. Exit interview conducted. A copy of today's report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2024

LIC809 (FAS) - (06/04)

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