565850186-12-20-2021-29-AS-MGCZ-C9VT6C-20211220132654

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850186
Report Date: 12/20/2021
Date Signed: 12/20/2021 01:28:03 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:	COTTAGES AT THE COLONY OF THOUSAND OAKS #1		FACILITY NUMBER:	565850186
ADMINISTRATOR:	ROUSH, CONNIE		FACILITY TYPE:	740
ADDRESS:	189 VENUS STREET		TELEPHONE:	(818) 479-3700
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	12/20/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:00 AM
MET WITH:	Connie Roush		TIME COMPLETED:	01:26 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 Guzman Chavez arrived unannounced at 10:00 a.m. for a pre-licensing inspection. The LPA met with applicant Connie Roush. This is a change of ownership application from The Colony Thousand Oaks #1 (#565850138) to Cottages at the Colony of Thousand Oaks #1 (#565850186). The current census is 5 residents. The fire clearance was granted on 07/02/2021; in which all rooms were cleared for bedridden clients. KITCHEN: Appliances in the kitchen were clean and all appeared functional. Knives and sharps are locked and inaccessible in a drawer next to the oven. The supply of perishable and nonperishable food is adequate. BEDROOMS: There are seven bedrooms in the facility; there are five (5) bedrooms for resident use, and two (2) staff rooms. The staff rooms are kept locked. All rooms have direct access to the outside. Lighting in the rooms appeared adequate. All five (5) resident rooms were set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. BATHROOMS: There are three full bathrooms. There are two (2) bathrooms for resident use and one (1) for staff use only. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. One out of the five (5) resident rooms has an attached bathroom, and the other resident bathroom is in the hallway. Hot water temperature was measured in the two (2) resident bathrooms; the 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: COTTAGES AT THE COLONY OF THOUSAND OAKS #1	FACILITY NUMBER: 565850186
	VISIT DATE: 12/20/2021

NARRATIVE

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Continued from LIC 809...

COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. The facility smoke alarm system is hard wired; the smoke detectors and carbon monoxide detectors were operable at the time of the visit. The fire extinguisher was fully charged and last serviced 12/18/2021. There is a functioning telephone on the premises. Emergency exiting plans/sketch and emergency telephone numbers are posted in the hallway. Other required postings are posted in the hallway upon entry into the facility. The 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 client use. Main temperature displayed in the hallway read at 82 degrees Fahrenheit.

MEDICATIONS: Medications are in a locked closet in the hallway. First aid kits and manual were observed to be complete.

FILES: Staff and client files are stored locked and inaccessible in the garage. All five (5) resident and five (5) staff files were reviewed at 10:41 a.m. and all records were in order.

LAUNDRY: The laundry area is in the hallway, directly across from the garage. Cleaning supplies and chemicals are stored and inaccessible to clients.

GARAGE AND GROUNDS: The garage is locked and attached to the house. There are two (2) additional refrigerators in the garage with perishable items in good condition. There is a covered patio area with patio furniture including a table and chairs for client use. Facility has one (1) fence gate that self-latches with clear passageways for emergency exit use. No large bodies of water accessible to clients at the time of visit. The facility has a central entry point for symptom screening and sanitation station for staff, clients and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.
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

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: COTTAGES AT THE COLONY OF THOUSAND OAKS #1	FACILITY NUMBER: 565850186
	VISIT DATE: 12/20/2021

NARRATIVE

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Continued from LIC 809C...

Component III was completed in conjunction with the visit.

Applicant has not completed Component II yet.

Facility is in compliance with Title 22 Regulations at this time. A copy of this report will be forwarded to the application specialist with LPA recommendation for licensure.

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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