565850186-2-3-2023-29-AS-MARO-CNPTNV-20230203135322

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850186
Report Date: 02/03/2023
Date Signed: 02/03/2023 01:53:30 PM

Document Has Been Signed on 02/03/2023 01:53 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:	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: 6	DATE:	02/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:00 PM
MET WITH:	Connie Roush		TIME COMPLETED:	02:10 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. This will be the first Annual conducted as the pre-licensing visit at this facility was on 12/20/2021. This annual has a specific emphasis on infection control practices and procedures. Upon arrival, LPA met with Administrator, Connie Roush and the reason for the visit was explained. Entrance interview.

At 12:20 p.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. LPA observed knives and sharps in a drawer locked and inaccessible to residents in care. LPA observed the resident rooms, which were furnished appropriately with linens, furnishings, and sufficient lighting. 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. Bathrooms were measured for hot water; the first bathroom measured at 109.4 degrees Fahrenheit at 12:27 p.m., second bathroom measured at 111.2 degrees Fahrenheit at 12:28 p.m., and third bathroom measured at 105.8 degrees Fahrenheit at 12:33 p.m. The garage is locked and attached to the house. Cleaning supplies and chemicals were observed to be stored and inaccessible to residents in care. There are two (2) additional freezers in the garage with perishable items in good condition. There is a covered patio area with patio furniture including several tables and chairs for resident use. Facility has one (1) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents during time of visit.

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: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 02/03/2023

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
26
27
28
29
30
31
32

Report Continued from LIC 809...

The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. Medications are in a locked closet adjacent to the living room. LPA observed three (3) residents in the living room watching television during time of visit.

During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, and posted CDSS PINS. 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 staff vaccination requirements. All staff are fully vaccinated and boosted. 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.

Exit interview conducted. No citations issued at the time of visit. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

Page: 2 of 2