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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565802432
Report Date: 09/12/2022
Date Signed: 09/12/2022 10:12:34 AM


Document Has Been Signed on 09/12/2022 10:12 AM - 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 IIIFACILITY NUMBER:
565802432
ADMINISTRATOR:JESSICA ACLKLINFACILITY TYPE:
740
ADDRESS:1959 HENDRIX AVETELEPHONE:
(805) 852-8791
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 5DATE:
09/12/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Dylan HullTIME COMPLETED:
10:15 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 Administrator Dylan Hull and Manager Tracy Varnell and explained the reason for the visit. The LPA toured the physical plant to ensure there are no health and safety hazards and facility is 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: Six out of seven rooms are for resident use; one bedroom is a staff room. Bedrooms had appropriate furnishings, clean linens and sufficient lighting. RESTROOMS: Resident restrooms were clean and sanitary with grab bars and non-skid surfaces. At 10:45 a.m., water temperature measured at 118.3 F. The LPA observed hand hygiene signs in all restrooms. COMMON SPACES: Living room and dining furniture were observed to be in good condition. Exits have functioning auditory devices. Fire extinguishers were charged and purchased in the last twelve months. Required postings were observed throughout the facility. The backyard and exterior area of the facility had furniture and a covered area for resident use. There were no bodies of water noted at the time of the visit.

INFECTION CONTROL: There is a central entry point for universal screening and temperature checks. Staff were observed wearing appropriate face masks. There is a centralized location with COVID-19 signs that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. There is sanitizer available for use throughout the facility. There is an adequate supply of Personal Protection Equipment (PPE). The facility’s cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. Staff are up to date regarding guidelines around visitation and vaccine requirements. The policies and procedures pertaining to infection control were adequate.

No deficiencies observed 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: 09/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/12/2022
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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