565850072-3-5-2021-29-AS-ASMH-BYTRBS-20210305115311

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850072
Report Date: 03/05/2021
Date Signed: 03/05/2021 11:54:24 AM

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:	SILVERADO THOUSAND OAKS, LLC		FACILITY NUMBER:	565850072
ADMINISTRATOR:	WILKIN, RONDA		FACILITY TYPE:	740
ADDRESS:	980 WARWICK AVE		TELEPHONE:	(805) 307-7300
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	82	CENSUS: 0	DATE:	03/05/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Ronda Wilkin		TIME COMPLETED:	12:00 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) Ashley Smith arrived at the facility at 9am for an announced pre-licensing inspection. Upon arrival, the LPA met with Executive Director Ronda Wilkin and Regional Administrator Jason Russo. The applicants successfully completed Component II on 2/12/2021 and Component III on 3/1/2021. A fire clearance was approved on 10/26/2020 and all rooms were cleared for non-ambulatory use. All rooms were cleared for bedridden use; however, this facility shall be limited to a maximum capacity of twelve (12) bedridden residents. This facility has an approved Hospice Waiver for twenty-five (25) residents. COMMON AREAS: The physical plant tour took place at 9:20am. The facility is a two story building. Facility has 2 working elevators and 2 stairwells. On the first floor, there are the kitchen facilities, dining room, Bistro, laundry rooms, Wellness Center, office spaces, and common restrooms. On the second floor, there is a sensory room, beauty salon, spa, Wellness Center, second floor dining, a private dining space, several activity spaces, office spaces and common restrooms. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. The facility uses a signal system, which is activated in resident units, bathrooms and common areas. Alerts are sent to the front desk but also to radios, which will be carried by staff. Residents will also have the option to use a pendant. System was tested randomly throughout the visit and it was in operating condition. There is a functioning telephone on the premises. There are cameras in the common areas, hallways, exits, outdoor courtyards, and exterior perimeter. The system can store footage for up to three weeks. Other required postings were observed in the hallway and at reception on the first floor. There are fire extinguishers throughout the facility, which were purchased 05/12/2020. The building received a final inspection from the fire department on 8/18/2020 and 10/15/2020 and smoke detectors, sprinkler system and carbon monoxide detectors were observed to be in operating condition. The carbon monoxide and smoke detectors are hardwired throughout the facility.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

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: SILVERADO THOUSAND OAKS, LLC	FACILITY NUMBER: 565850072
	VISIT DATE: 03/05/2021

NARRATIVE

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The LPA toured the outside area of the facility. There are three outdoor gated courtyards; two are on the first floor and one is on the 2^nd floor. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Facility has a 9-seat passenger bus for resident transportation needs. There were no bodies of water observed during today’s visit.

MEDICATION: There were two medication rooms in the facility. There were several complete first-aid kits and a surplus of medical supplies. The medication carts are equipped with a double locking system for narcotics.

KITCHEN: The main kitchen is located on the 1st floor. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries, and food delivery takes place twice a week. The facility has a seven-day emergency supply of food and water, which was observed to be in good condition at the time of the visit. The LPA obtained a seven-day menu during today’s visit.

RESIDENT ROOMS: The community is designated for all memory care residents. There are 24 units on the first floor and 23 units on the second floor. Out of the 47 units, 12 are identified as private occupancy, where the other rooms are designated for double occupancy. All rooms are complete, with properly installed grab-bars in resident bathrooms and non-skid strips in shower tubs. Appropriate furniture was also observed in the units. There are motion sensors installed in all units. Delayed egress was tested and it was operational at the time of the visit.

During today's visit, water temperature was randomly tested and temperature ranged between 111 to 116 degrees Fahrenheit, which is within the required range per regulation of 105 to 120 degrees Fahrenheit.

Physical plant is in compliance with Title 22 regulations. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate and accept residents until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/05/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/05/2021

LIC809 (FAS) - (06/04)

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