565801921-2-8-2023-29-AS-ECAS-CNUR7W-20230208114700

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801921
Report Date: 02/08/2023
Date Signed: 02/08/2023 11:47:36 AM

Document Has Been Signed on 02/08/2023 11:47 AM - 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 - FLORES		FACILITY NUMBER:	565801921
ADMINISTRATOR:	KATHIE A. FLOOD		FACILITY TYPE:	740
ADDRESS:	144 W. AVENIDA DE LAS FLORES		TELEPHONE:	(805) 379-1259
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	02/08/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:05 AM
MET WITH:	David Flood-Licensee Representative		TIME COMPLETED:	11:50 AM

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Licensing Program Analyst (LPA), Elsie Campos conducted an unannounced visit to Compassionate Care Residence - Flores to conduct a Required 1-Year Annual Inspection. This annual has a specific emphasis on infection control practices and procedures. The LPA was greeted and scanned at the door by staff, Mark Quiquis. The Licensee Representative, David Flood arrived shortly after and was explained the reason for the visit.

At 10:25 a.m., the LPA began the physical plant tour with staff 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: The LPA observed the kitchen/dining area to be clean and kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed the kitchen refrigerator to be fully stocked at the time of visit. Knives and sharps are locked in a drawer next to the kitchen sink inaccessible to residents. Hot water temperature measured at 119.4 degrees Fahrenheit at 11:13 a.m.

BEDROOMS: The LPA observed six (6) resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting. The facility has one (1) staff room used for changing or shift changes which was furnished and had sufficient lighting.

RESTROOMS: Resident bathrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces and handwashing signs. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The LPA observed two (2) bathrooms for resident use. Bathroom #1 hot water temperature measured 117.6 degrees Fahrenheit and Bathroom #2 bathroom measured 119.3 degrees Fahrenheit.

...Continued on LIC 809C...

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

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 - FLORES	FACILITY NUMBER: 565801921
	VISIT DATE: 02/08/2023

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…Continued from LIC 809...

COMMON SPACES: The LPA observed the living room area which is clean and properly furnished with seating, a table, and television for resident use. The LPA observed three (3) residents in the living room watching television during time of visit. Smoke detectors and Carbon Monoxide detectors are hardwired and interconnected. The LPA tested the fire alarm system at 10:57 a.m. and observed the system to be operating at the time of the visit. The LPA observed the fire extinguisher to be last purchased on 7/17/2022. Medications were observed in a locked cabinet inside the office adjacent to the living room. Locked cleaning supplies, emergency food supplies and additional incontinent supplies were also observed in the office adjacent to the living room.

GARAGE AND GROUNDS: The facility does not have a garage. The LPA observed 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. There were no bodies of water accessible to residents at the time of visit.

During today’s visit, the LPA spoke with the Licensee Representative 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). Staff were observed wearing face coverings. All staff are fully vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation.

Exit interview conducted. No deficiencies cited. 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: 02/08/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/08/2023

LIC809 (FAS) - (06/04)

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