<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802430
Report Date: 08/16/2023
Date Signed: 08/16/2023 03:44:35 PM


Document Has Been Signed on 08/16/2023 03:44 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
WOODLAND HILLS NORTH, 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: 6DATE:
08/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Dylan HullTIME COMPLETED:
03:45 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 Analysts (LPA) Esther Cortez conducted an unannounced Case Management -Deficiencies visit in conjunction with an initial 10-Day complaint visit (Complaint Control #29-AS- 20230811095354). The purpose of the visit is to issue citations for deficiency observed during the complaint investigation which is not related to the complaint. The LPA met with Administrators Dylan Hull and Kim Anderson and the reason for the visit was explained.

During facility tour at 9:53 a.m., the LPA observed UltraClean premium laundry detergent tide pods located on a shelf on top of the washer and dryer and tools in the garage accessible to residents in care located on top of cabinets. Upon observation, the administrator stated that the garage is locked, however the LPA observed that the garage is locked from the inside of the garage and anyone in the home has access to the garage and all items inside. During facility tour, at 9:57 a .m., the LPA observed an unlocked staff room with personal hygiene items inside. Staff room was locked and garage door knob was changed to lock from inside the garage making all items inaccessible to residents in care during the visit.



Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited
(refer to LIC 809-D).

Exit interview conducted. Copy of the report and appeal rights given to administrator .Dylan Hull
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
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


Document Has Been Signed on 08/16/2023 03:44 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: SELECT SENIOR LIVING I
FACILITY NUMBER: 565802430

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/17/2023
Section Cited
CCR
87705(f)(2)

1
2
3
4
5
6
7
87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: (2) Over-the-...and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Licensee properly locked both the garage and staff room and agrees to install digital locks on both staff room and garage by 8/17/2023.
8
9
10
11
12
13
14
Based on LPA's observations, the licensee did not comply with the section cited above as LPA observed detergent and tools inside a garage accessible to residents which poses an potential health and safety risk to persons in care.
8
9
10
11
12
13
14

1
2
3
4
5
6
7
1
2
3
4
5
6
7

1
2
3
4
5
6
7
1
2
3
4
5
6
7
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Esther CortezTELEPHONE: (747) 230-2225
LICENSING EVALUATOR SIGNATURE:
DATE: 08/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/16/2023
LIC809 (FAS) - (06/04)
Page: 2 of 2