565802412-2-28-2025-29-AS-KDUK-DEBVCG-20250228151908

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802412
Report Date: 02/28/2025
Date Signed: 02/28/2025 03:19:16 PM

Document Has Been Signed on 02/28/2025 03:19 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/ DIRECTOR:	FLOOD, KATHIE ANN		FACILITY TYPE:	740
ADDRESS:	1376 HENDRIX AVE		TELEPHONE:	(805) 379-9675
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 6	DATE:	02/28/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:57 AM
MET WITH:	Kathie Flood and David Flood		TIME VISIT/ INSPECTION COMPLETED:	03:25 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 Analysts (LPAs) Kelly Dulek and Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 11:57AM. The LPAs were greeted by staff and informed them of the reason for the visit. Administrator Kathie Flood and co-Administrator David Flood arrived shortly thereafter.

Beginning at 01:06PM, the LPAs and Administrators 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. The following was observed:

BEDROOMS/RESTROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are six (6) designated resident rooms, 1 (one) staff room and 1 (one) staff break room. There are 3 (three) total bathrooms in the facility; 1 (one) is designated as a shared resident restroom, 1 (one) is a private bathroom and 1 (one) is designated as a staff restroom. Restrooms were clean and sanitary and in operating condition with grab bars and non-slip surfaces. All restrooms were sufficiently stocked with soap and paper towels. Hot water was tested in the common restroom and measured within the required range.

COMMON AREAS: At the time of the visit, living room, family room, and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which was observed to be screened and inaccessible. The facility maintained a comfortable temperature throughout the visit. Hardwired combination smoke and carbon monoxide detectors as well as fire doors were tested at 01:37PM and were operational at the time of the visit. The fire extinguisher was fully charged and purchased on 02/25/2025. The LPAs observed required postings on the dining room wall.

KITCHEN: The LPAs observed the facility kitchen. 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. Continued on LIC 809-C

Kristin Heffernan	TELEPHONE: (818) 596-4493
Kelly Dulek	TELEPHONE: (951) 836-3170
	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 02/28/2025

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
26
27
28
29
30
31
32

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for resident use. There are 2 (two) side gates for emergency exit use and are 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 LPAs observed additional perishable and non-perishable food supply, emergency water, additional Personal Protection Equipment (PPE) and supplies.

RECORDS: Records review began at 12:20PM. Resident records were reviewed for, but not limited to care plans, physician's report, 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 02:16PM; medications are centrally stored and kept locked in a cabinet in the office. Medications were observed for 2 (two) residents. 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/EMERGENCY DISASTER PLAN: During today's visit, LPAs reviewed the facility's infection control plan and emergency disaster plan. The facility's procedures as it pertains to infection control are adequate. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 01/24/2025.

INTERVIEWS: During today's visit, LPAs interviewed 1 (one) staff and 2 (two) residents. No concerns were noted.

The LPAs obtained the following documents:

- LIC500 Personnel Report
- Liability Insurance

No deficiencies cited. Exit interview conducted. A copy of today's report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 02/28/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/28/2025

LIC809 (FAS) - (06/04)

Page: 2 of 2