565802412-2-10-2023-29-AS-MARO-CNWS3Q-20230210123130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802412
Report Date: 02/10/2023
Date Signed: 02/10/2023 12:31:41 PM

Document Has Been Signed on 02/10/2023 12:31 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: 6	DATE:	02/10/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Marilon Manalang		TIME COMPLETED:	12:35 PM

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Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual with focus on Infection Control. The last Annual visit conducted at this facility was on 03/10/2022. Upon arrival, LPA met with staff Marilon Manalang and the reason for the visit was explained. Entrance Interview.

At 10:48 a.m., the LPA along with staff began the physical plant tour of the common areas kitchen area, resident bedrooms, bathrooms, staff room, office, and outdoor area to ensure there are n􀀁 health and safety hazards and facility is in compliance with Title 22 Regulations.

LPA observed two resident bathrooms for hot water temperature; the first bathroom measured at 107.6 degrees Fahrenheit at 10:50am; and the second bathroom measured 113 degrees Fahrenheit at 11:00am. The kitchen sink was also measured for hot water temperature and it measured at 107.8 at 10:53am. LPA observed an adequate amount of perishable and non-perishable food. Cleaning supplies and toxins were observed locked and inaccessible. LPA observed the fire extinguishers to be fully charged. At 10:58am, the smoke detectors and carbon monoxide detectors were tested and operable. LPA observed medications locked and inaccessible. The facility was maintained at 77 degrees Fahrenheit at the time of visit. LPA observed outdoor grounds with clear passageways free of obstruction. No bodies of water observed at the time of visit.

Report Continued on LIC 809C ...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

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-HENDRIX	FACILITY NUMBER: 565802412
	VISIT DATE: 02/10/2023

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Report Continued from LIC 809 ...

During today's visit, LPA spoke with the staff 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) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVlD-19. All staff are fully vaccinated and boosted. Staff were observed wearing face coverings at the time of visit. No identified staffing concerns.

Exit interview conducted. No citations issued during today's visit. Copy of the report was issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 02/10/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2023

LIC809 (FAS) - (06/04)

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