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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802431
Report Date: 09/10/2022
Date Signed: 09/10/2022 01:17:27 PM


Document Has Been Signed on 09/10/2022 01:17 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 IIFACILITY NUMBER:
565802431
ADMINISTRATOR:KATHLEEN LEITERMANFACILITY TYPE:
740
ADDRESS:113 ERTEN STREETTELEPHONE:
(805) 852-8789
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
09/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Tracy VarnellTIME COMPLETED:
10:45 AM
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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 explained the reason for the visit. Administrator Dylan Hull was notified of today’s visit. The LPA toured the facility to ensure there were no hazards and facility was in compliance with Title 22 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: The six (6) resident rooms had appropriate furniture, clean linens and sufficient lighting. Rooms were clean and clear of obstructions. There is a staff room that is kept locked. RESTROOMS: The restrooms were clean and sanitary with grab bars and non-skid surfaces. At 10:01 a.m., water temperature measured at 110.3 F. Restrooms were stocked with soap and paper towels. COMMON SPACES: The facility maintained a temperature of 74 degrees. Smoke detectors and carbon monoxide detectors were operable. Living room and dining furniture were observed in good condition. Fire extinguishers was purchased within the past twelve months. 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. The garage is attached and was equipped with a large supply of Personal Protection Equipment (PPE) and additional food. The garage is kept locked.

INFECTION CONTROL: There is a central entry point for screening and temperature checks. Appropriate infection control signage was observed throughout the facility and on the front door. Bathrooms had appropriate hand-washing signs. The 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 for visitation and vaccine requirements. The Provider Information Notices (PINs) were posted. The policies and procedures pertaining to infection control were adequate.

No deficiencies cited at this time. Exit interview conducted. Report issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley SmithTELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:
DATE: 09/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/10/2022
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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