565802432-10-16-2023-29-AS-MARO-CWNSTT-20231016141006

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565802432
Report Date: 10/16/2023
Date Signed: 10/16/2023 02:10:12 PM

Document Has Been Signed on 10/16/2023 02:10 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 III		FACILITY NUMBER:	565802432
ADMINISTRATOR:	DYLAN HULL		FACILITY TYPE:	740
ADDRESS:	1959 HENDRIX AVE		TELEPHONE:	(805) 852-8791
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	10/16/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Kin Anderson		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) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:30 a.m. Upon arrival, there were two staff and five residents present. The Administrator, Kim Anderson arrived at 9:40 a.m. and the reason for the visit was explained. Entrance interview conducted. At 9:45 a.m., the LPA along with the Administrator 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 toured the kitchen/food service area at 9:50 a.m. The hot water was measured at 110.3 degrees Fahrenheit at 9:51 a.m. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperature. There was a sufficient amount of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. Food had labels clearly marked with dates. Knives and sharps were observed locked in a drawer. Cleaning supplies were stored under the kitchen sink locked and inaccessible. There were no pesticides or poisons observed near any food areas. LIVING ROOM/DINING ROOM: The LPA inspected the living room and dining room area. The common areas were observed to be properly furnished and relatively clean at the time of the visit. Furniture was observed to be in good condition. Fireplace was observed to be adequately screened at the time of the visit. The facility maintained a comfortable temperature. (Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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 III	FACILITY NUMBER: 565802432
	VISIT DATE: 10/16/2023

NARRATIVE

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(Report Continued from LIC 809...)

At 10:04 a.m., the smoke detector(s) and carbon monoxide detectors were tested and operational. Fire extinguishers were observed fully charged and purchased on 05/15/2023. The LPA observed required postings throughout the common spaces. The facility has a working telephone on premises. Auditory alarms on all doors were functional at the time of the visit. Entry/exits were free of obstruction. There is a separate room with a washer and dryer that is kept inaccessible to residents at all times.

GARAGE/OUTDOORS: There is a garage that is kept locked and inaccessible at all times. There was another refrigerator observed with additional food. An adequate supply of emergency food and water was observed. The LPA observed a sufficient supply of Personal Protectant Equipment (PPE). Cleaning supplies and toxins were observed in the garage inaccessible to residents in care. The backyard has a shaded area with furniture for resident use. The LPA observed one gate that self-latches with a clear passageway in case of an emergency. There were no bodies of water noted at the time of the visit.

BEDROOMS: There are six (6) resident bedrooms. The resident bedrooms were properly furnished with a bed, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. There is one (1) staff bedroom that is locked at all times.

BATHROOMS: There are three (3) bathrooms for resident use. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit between 9:48 a.m. and 10:00 a.m.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

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 III	FACILITY NUMBER: 565802432
	VISIT DATE: 10/16/2023

NARRATIVE

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(Report Continued from LIC 809C...)

RECORDS: Records review began at 10:18 a.m., five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time.

Two (2) Personnel records and 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 files were in order.

Although the facility does not have Personnel files at the facility; they are readily available upon request.

Fire and earthquake drills were conducted within the last 6 months as per regulation; the last one conducted 09/14/2023.

MEDICATIONS: Medications review began at approximately 12:10 p.m. Medications are centrally stored in a cabinet by the kitchen locked and inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No medication errors observed at this time.

The LPA interviewed one (1) staff during the inspection.

During today’s visit, the LPA obtained copies of the following: LIC 500 Personnel Report, LIC 9020 Resident Roster, and current liability insurance.

Exit interview conducted. A copy of the report were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/16/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023

LIC809 (FAS) - (06/04)

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