565802431-10-11-2024-29-AS-EMOY-D9XUMQ-20241011154242

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802431
Report Date: 10/11/2024
Date Signed: 10/11/2024 03:44:44 PM

Document Has Been Signed on 10/11/2024 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SELECT SENIOR LIVING II		FACILITY NUMBER:	565802431
ADMINISTRATOR:	KATHLEEN LEITERMAN		FACILITY TYPE:	740
ADDRESS:	113 ERTEN STREET		TELEPHONE:	(805) 852-8789
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	10/11/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Dylan Hull - Administrators and Kimberly Anderson - Administrator		TIME COMPLETED:	04:00 PM

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Licensing Program Analysts (LPA) Erica Mosley arrived at the facility unannounced to conduct a required annual visit and entered the facility at 9:45 a.m. Upon arrival, LPA Mosley was greeted by staff and called the administrator to inform them of the visit. The administrator arrived shortly thereafter. The LPA met with Kimberly Anderson – Administrator and explained the reason for the visit. Dylan Hull - Administrators / Licensee Representative arrived during the visit. The LPA 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.

KITCHEN: The LPA inspected the kitchen/food service area at 10:40 a.m. Knives and sharps were observed in a locked cabinet. Kitchen appliances were in operable condition. Chemical storage is kept locked under the sink. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. The kitchen faucet was measured for hot water temperature, and it measured 117.1 degrees Fahrenheit at 10:42 a.m.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. At 3:24 p.m., hardwire combination of smoke / carbon monoxide detector and fire doors were tested and operational at the time of the visit. The fire extinguisher was observed and fully charged on 5/28/2024. The LPA observed required postings throughout the common space. The last emergency disaster drill took place on 08/27/2024 and conducted quarterly. Activities were observed in the common areas. A non-functional fireplace was noted in the living room. Adjacent to the kitchen is a laundry room, with a washer and dryer. Laundry detergent was observed in a locked cabinet above the washer and dryer.

Report Continued on LIC 809C 2nd page...

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SELECT SENIOR LIVING II	FACILITY NUMBER: 565802431
	VISIT DATE: 10/11/2024

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Report Continued from LIC 809...
(LIC 809C... 2nd page)
RESTROOMS: There are four (4) restrooms. Three (3) 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 restrooms were sufficiently stocked with supplies and paper towels. The water temperature was measured in resident restrooms ranging between 113.5 -114.4 degrees Fahrenheit all within the required range.

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.
GARAGE/BACKYARD: The garage is maintained locked at all times. LPA observed an adequate amount of emergency food and water. Cleaning supplies are kept in the garage locked and inaccessible to residents in care. 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. LPA observed one (1) self-latching gate. There were no bodies of water noted at the time of the visit.

MEDICATIONS: Medications review began at approximately 12:06 p.m. The medications are in a locked medication cart adjacent to the kitchen. Medications for four residents were reviewed. Medications reviewed were found to be self administered as prescribed and documented on the centrally stored medication and destruction records.

(LIC 809C... 2nd page)
Report Continued to LIC 809C.. 3rd page .

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SELECT SENIOR LIVING II	FACILITY NUMBER: 565802431
	VISIT DATE: 10/11/2024

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Report Continued from LIC 809C 2nd page
LIC 809C 3rd page

RECORDS: Record review began at approx. 11:00 am. Personnel Records were reviewed beginning at 11:07 a.m. and Resident Records at 11:45 a.m. Six (6) Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Four (4) Personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All records were in order.

INTERVIEWS: Two (2) staff interviews were conducted. Six (6) resident interviews were attempted, two (2) interviews were conducted during the inspection.

No deficiencies were cited during today’s inspection. Exit interview conducted. A copy of the report provided via email due to printer issues.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Erica Mosley	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/11/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/11/2024

LIC809 (FAS) - (06/04)

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