565802430-10-22-2023-29-AS-KDUK-CWUSUM-20231022141123

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802430
Report Date: 10/22/2023
Date Signed: 10/22/2023 02:11:28 PM

Document Has Been Signed on 10/22/2023 02:11 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 I		FACILITY NUMBER:	565802430
ADMINISTRATOR:	HULL, DYLAN		FACILITY TYPE:	740
ADDRESS:	1363 FEATHER AVE		TELEPHONE:	(805) 852-5059
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	10/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Dylan Hull		TIME COMPLETED:	02:15 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 Analyst (LPA) Kelly Dulek arrived unannounced to conduct a required annual visit. The LPA initially met with facility staff. Administrator Dylan Hull was contacted via telephone and arrived at 11:20AM. LPA explained the reason for the visit. Entrance interview conducted. Beginning at 11:30AM, the LPA, along with Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguisher is fully charged and purchased on 05/15/2023. Hardwired combination smoke/carbon monoxide detectors and fire doors were tested at 01:48 PM and were functional. A copy of the current liability insurance was obtained during today's visit. COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. An non-functional fireplace was noted in the living room. BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated as private resident rooms and one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. BATHROOMS: There are three (3) bathrooms. Two (2) are designated for resident use and one (1) is a staff/guest restroom. Resident restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in both resident bathrooms and measured within the required range. Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

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: SELECT SENIOR LIVING I	FACILITY NUMBER: 565802430
	VISIT DATE: 10/22/2023

NARRATIVE

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OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. All passageways were observed to be clear. There were no bodies of water on the premises.

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. Cleaning supplies are located in a locked cabinet under the kitchen sink. Knives are stored in a locked kitchen drawer.

GARAGE: Garage was observed locked and contained laundry area, extra food, PPE and incontinence supplies, and emergency food and water.

RECORD REVIEW: Began at 11:55AM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. All five (5) staff files and five (5) resident files observed were in compliance with regulation.

MEDICATION REVIEW: Began at 12:57PM. Medications for two (2) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill conducted on 09/28/2023. Emergency disaster plan was observed to be complete and updated annually, as required.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and two (2) residents.

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: 10/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/22/2023

LIC809 (FAS) - (06/04)

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