565850138-12-20-2021-29-AS-MGCZ-C9VT3P-20211220132240

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850138
Report Date: 12/20/2021
Date Signed: 12/20/2021 01:23:12 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: 5	DATE:	12/20/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Connie Roush		TIME COMPLETED:	01:20 PM

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Licensing Program Analyst (LPA) Martha Guzman Chavez arrived at the facility unannounced to conduct a required annual visit at 10:00 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Connie Roush and explained the reason for the visit. Entrance interview.

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: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed one designated drawer next to the oven where knives and sharps are locked and inaccessible to residents.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed in the restrooms. Bathrooms were measure for hot water, first bathroom measured at 105.8 degrees Fahrenheit and the second bathroom measured at 105.2 degrees Fahrenheit.

Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

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: COLONY - THOUSAND OAKS 1, THE	FACILITY NUMBER: 565850138
	VISIT DATE: 12/20/2021

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Continued from LIC 809...

COMMON SPACES: In the common areas, walls, flooring and furniture were checked for cleanliness and were in good condition. The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. Main temperature displayed in the hallway read at 82 degrees Fahrenheit. The garage is locked and inaccessible. The LPA observed laundry area with all disinfectants and detergents locked and inaccessible to residents. Required postings were observed in the entryway. All exits had a functioning auditory device. The LPA observed a covered patio area with patio furniture including a table and chairs for resident use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to residents.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) in the garage and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The LPA and Administrator discussed the recent PIN as it relates to visitation and staff vaccination requirements. All staff and residents are vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies cited. Exit interview conducted. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 12/20/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/20/2021

LIC809 (FAS) - (06/04)

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