565801812-9-12-2023-29-AS-ECAS-CVLV7L-20230912161118

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801812
Report Date: 09/12/2023
Date Signed: 09/12/2023 04:12:27 PM

Document Has Been Signed on 09/12/2023 04:12 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:	09/12/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:00 PM
MET WITH:	David Flood and Kathie Flood		TIME COMPLETED:	04:25 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 1:00 p.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator David Flood arrived shortly thereafter. The LPA and administrator 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. BEDROOMS/BATHROOMS: The LPA began the inspection with the bedrooms and bathrooms at 1:20 p.m. Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six (6) designated resident rooms and one (1) staff room. The resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature measured between 114.2 and 115.3 degrees Fahrenheit between 1:25 p.m. and 1:32 p.m. KITCHEN: The LPA continued the inspection in the kitchen/food service area. 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. COMMON AREAS: At the time of the visit, living room and dining room furniture were observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 74 degrees. Smoke detector(s) and carbon monoxide detector were tested at 1:42 p.m. and operational at the time of the visit. The fire extinguisher was fully charged and purchased on September 12, 2023. The LPA observed required postings on the dining room wall. Continued on LIC 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

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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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: 09/12/2023

NARRATIVE

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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 and additional Personal Protection Equipment (PPE).

RECORDS: Residents’ records review began at 1:50 p.m., records were reviewed for, but not limited to care
plans, medical records, 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 2:35 p.m.; medications are centrally stored and kept locked in a cabinet in the office. 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: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA obtained the following documents:
- LIC500 Personnel Report
- LIC9020 Resident Roster
- Liability Insurance

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 09/12/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/12/2023

LIC809 (FAS) - (06/04)

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