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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802430
Report Date: 09/09/2022
Date Signed: 09/09/2022 02:54:29 PM


Document Has Been Signed on 09/09/2022 02:54 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:SELECT SENIOR LIVING IFACILITY NUMBER:
565802430
ADMINISTRATOR:HULL, DYLANFACILITY TYPE:
740
ADDRESS:1363 FEATHER AVETELEPHONE:
(805) 852-5059
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 4DATE:
09/09/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Dylan HullTIME COMPLETED:
01:30 PM
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Licensing Program Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA met with House Manager Tracy Varnell and Administrator Dylan Hull and explained the reason for the visit. The LPA toured the facility to ensure there are no health and safety hazards and to ensure compliance with regulations.

KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Bedrooms had appropriate furniture, clean linens and sufficient lighting. Rooms were clean and clear of obstructions. Both the single-occupancy resident rooms and staff rooms were observed. RESTROOMS: The three restrooms were clean and sanitary with grab bars and non-skid surfaces. Water temperature measured at 105.1 F. Restrooms were stocked with soap and paper towels. Hand-washing signs were observed in all restrooms. COMMON SPACES: The facility maintained a temperature of 74 degrees. Medications, staff and resident files are locked inaccessible. Fire extinguishers were fully charged. The backyard and exterior area of the facility had furniture and a covered area for resident use. No obstructions observed in the exterior or interior. No bodies of water noted.

INFECTION CONTROL: There is a central entry point for screening and temperature checks. Staff were wearing appropriate face coverings. Signs were posted that promoted good hand hygiene, physical distancing, and cough/sneeze etiquette at the front door and the entrance. The facility’s cleaning protocol is sufficient. There is record of staff and resident vaccinations. The facility can designate a room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines around visitation and vaccine requirements. The policies and procedures pertaining to infection control were adequate.

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 09/09/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2022
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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