565850138-12-16-2020-29-AS-RDLN-BWCSXW-20201216131638

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850138
Report Date: 12/16/2020
Date Signed: 12/16/2020 01:17:30 PM

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:	COLONY - THOUSAND OAKS 1, THE		FACILITY NUMBER:	565850138
ADMINISTRATOR:	LEVENTER, DVORA		FACILITY TYPE:	740
ADDRESS:	189 VENUS STREET		TELEPHONE:	(805) 300-8707
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	12/16/2020
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	11:00 AM
MET WITH:	Debbie Leventer, Administrator		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) Rachael De Leon conducted a Pre-Licensing Inspection with Administrator Connie Rousch. Due to the situation surrounding the Coronavirus Disease 2019 (COVID-19), and to implement mitigation measures, today’s visit was conducted virtually with the use of "FaceTime". An Application to operate a Residential Care Facility for the Elderly (RCFE) was received by Community Care Licensing (CCL). A Fire Clearance was approved for a maximum capacity of six (6) residents, all of which may be bedridden, on 10/23/2020. The application is for change of ownership (CHOW), residents are present in the facility. Physical Plant: The facility is a one (1) story single family dwelling located in a residential neighborhood. A tour of the physical plant was conducted and the following observed: The facility has hard wired dual smoke and carbon monoxide detectors in all common areas and smoke detectors in all bedroom, the facility has a hardwired sprinkler system, and a large fire door in the hallway. Smoke/carbon alarms were tested and functioning properly. Fire extingushers are charged and reciept with date of purchase 09/14/2020. The facility has all exiting doors alarmed, tested and working properly. The facility is a 7 bedroom with 3 full baths and 1 half bathroom, 1 bedroom #7 is designated for staff use. KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient perishable food to accommodate a maximum capacity of six (6) residents for a minimum of two (2) days. There was sufficient nonperishable food to accommodate a maximum capacity of 6 residents for (seven) 7 days. Hot water delivered at 111.1 F. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 residents. Trash cans have tight fitting lids. Three drawers have magnetic locks for sharps and knives. There were no visible immediate hazards or discrepancies observed. BEDROOMS: There are seven (7) Bedrooms, six of which are designated for Resident use. The bedrooms are furnished for single occupancy. There was appropriate furniture,

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020

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: COLONY - THOUSAND OAKS 1, THE	FACILITY NUMBER: 565850138
	VISIT DATE: 12/16/2020

NARRATIVE

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bedding and linens. There were no visible hazards or discrepancies observed.
BATHROOMS: There are four (3) full bathrooms and 1 half bath. Three bathrooms are designated for residents and the remaining bathroom is designated for staff and resident use. All bathrooms are equipped with appropriate grab bars and supplied with appropriate paper and hygiene products. All showers and tubs have grab bars and non-skid mats. Trash cans have tight fitting lids. There were no visible hazards or discrepancies.
COMMON AREAS: These include the living room and a dining Room. The common areas were furnished to accommodate a maximum capacity of six (6) residents. All required postings were located inside the main entrance. CCL complaint poster and LTCO poster are hung on the walls in the dining room. There is hand sanitizer with sign in sheets at the main entrance. Required COVID-19 postings were located at the main entrance both interior and exterior and throughout the facility. There were no visible hazards or discrepancies.
MEDICATION CLOSET: The medication closet is locked and inaccessible to residents in care. The First Aid Kit has all required supplies and a manual is present. Residents medication records are kept confidential and locked.
STAFF AREA: There is one bedroom designated for Staff use.
LAUNDRY ROOM: The laundry room is kept locked. The room has a working washer and dryer. Laundry and cleaning supplies are kept inaccessible to residents in care.
SURROUNDING GROUNDS: The Front Yard has a driveway, paved walk ways and landscaped areas. The Back Yard is fenced with self latching and self closing gates. The paved walking paths are free from any obstructions. The patios are furnished appropriately and a covered shaded area with umbrella is provided for residents. The ramps leading out to the back and side yards were checked and are all in good condition There were no visible immediate hazards or deficiencies.
GARAGE: Attached to the facility and it is kept locked inaccessible to residents in care, has several shelving units with emergency food, water, and a cooler for emergency medication transport, additional personal hygiene, grooming supplies and cleaning supplies are kept on separate shelf's in this area.

A copy of the Licensing Report was provided via email for signature and return.

SUPERVISOR'S NAME: Kelly Burley	TELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De Leon	TELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:	DATE: 12/16/2020

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/16/2020

LIC809 (FAS) - (06/04)

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