565802412-3-10-2022-29-AS-MGCZ-CCDVBL-20220310151742

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802412
Report Date: 03/10/2022
Date Signed: 03/10/2022 03:18:29 PM

Document Has Been Signed on 03/10/2022 03:18 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-HENDRIX		FACILITY NUMBER:	565802412
ADMINISTRATOR:	FLOOD, KATHIE ANN		FACILITY TYPE:	740
ADDRESS:	1376 HENDRIX AVE		TELEPHONE:	(805) 379-9675
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	03/10/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	David / Kathie Flood		TIME COMPLETED:	03:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Guzman Chavez arrived at the facility unannounced to conduct a required annual visit at 1:25 p.m. The last annual conducted at this facility was on 2/05/2020. This annual has a specific emphasis on infection control practices and procedures. The LPA was greeted and scanned at the door by staff Marilona Manalang. The Licensee Representatives, David and Kathie Flood arrived shortly after and were explained the reason for the visit. Entrance interview.

The LPA began the physical plant tour with the Licensee Representatives 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 knives and sharps to be stored in a locked drawer next to the kitchen sink inaccessible to residents. Medications are in a locked cabinet adjacent to living room.

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. The LPA observed two bathrooms for resident use. The first bathroom is private in bedroom #1 and it measured at 107.8 degrees Fahrenheit and the second bathroom measured at 107.6 degrees Fahrenheit.

...Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

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-HENDRIX	FACILITY NUMBER: 565802412
	VISIT DATE: 03/10/2022

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…Continued from LIC 809...

COMMON SPACES: The LPA observed two living room areas which are clean and properly furnished with seating, a table, and television for resident use. The LPA observed all five residents in the second living room watching television during time of visit.

GARAGE AND GROUNDS: The garage is locked and attached to the house. There is one additional freezer in the garage with perishable items in good condition. The LPA observed a covered patio area with patio furniture including a table and chairs for resident use. Facility has two fence gates that self-latch with a clear passageway for emergency exit use. There were no large bodies of water accessible to residents.

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 the necessary 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 and residents are fully vaccinated and boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation.

Exit interview conducted. No citations issued. A copy of the report will be provided to Licensee Representative via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 03/10/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022

LIC809 (FAS) - (06/04)

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