565801921-4-10-2024-29-AS-ZCHN-D4858Q-20240410194419

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801921
Report Date: 04/10/2024
Date Signed: 04/10/2024 07:45:36 PM

Document Has Been Signed on 04/10/2024 07:45 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 - 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:	04/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	03:49 PM
MET WITH:	David and Kathie Flood		TIME COMPLETED:	06:45 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) Zabel Chochian conducted an annual required visit to this facility today. The LPA was greeted and scanned at the door by staff. Licensee/Administrators, David and Kathie Flood arrived shortly after and reason for the visit was explained. At approximately 3:50pm, 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. BEDROOMS: The LPA observed six (6) resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting. The facility has only one (1) staff room across from the laundry area. RESTROOMS: Resident bathrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap, paper towels and toilet paper. Hot water temperature measured between 116-118 degrees Fahrenheit. COMMON SPACES: The LPA observed the living room area which is clean and properly furnished with seating, a table, and television for resident use. Smoke detectors and Carbon Monoxide detectors are hardwired and interconnected. The LPA tested the fire alarm system and observed the system to be operating at the time of the visit. The LPA observed the fire extinguisher to be last purchased in 10/18/2023. 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. Also a room designated as a staff break/changing room for shift changes was observed in the office area. 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. No bodies of water accessible to residents at the time of visit. (Continue to LIC809C.)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

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 - FLORES	FACILITY NUMBER: 565801921
	VISIT DATE: 04/10/2024

NARRATIVE

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MEDICATIONS: Medications review began at 4p.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.

RECORDS: Residents’ records review began at 4:45p.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 all other required trainings. Training records observed were missing the time of training. Discussion was held regarding training record keeping and Administrators and Licensee acknowledged understanding of this requirement and stated that moving forward they will ensure the time of training is documented.
The LPA obtained the following documents:
- Liability Insurance

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

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 04/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/10/2024

LIC809 (FAS) - (06/04)

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