565850187-9-28-2021-29-AS-MGCZ-C7ARVZ-20210928132223

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850187
Report Date: 09/28/2021
Date Signed: 09/28/2021 01:23:09 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:	451 COLUMBIA LLC		FACILITY NUMBER:	565850187
ADMINISTRATOR:	SHERMAN, GILLIANA		FACILITY TYPE:	740
ADDRESS:	451 COLUMBIA ROAD		TELEPHONE:	(805) 807-0663
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	09/28/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	10:50 AM
MET WITH:	Gilliana Sherman		TIME COMPLETED:	01:21 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 conducted an announced Pre-licensing visit to the above facility on 9/28/2021 at 10:50 am. LPA met with Licensee Representative Gilliana Sherman as this is a change of ownership application from Thousand Oaks Home Care VI #565801484 to 451 Columbia LLC #565850187. Licensee Representative completed Comp II on 09-10-2021 and Comp III on 09-24-2021. Entrance interview conducted. The applicant has obtained fire clearance for a total capacity of 1 (one) bedridden and 5 (five) non-ambulatory, for a total capacity of six (6) clients. Facility currently has six (6) non-ambulatory residents. Facility has seven (7) bedrooms and three and a half (3 1/2) bathrooms. Five (5) resident bedrooms are single occupancy. Residents’ bedroom #6 has double occupancy as residents are married/together. Seventh bedroom is for staff. LPA observed a central entry point by the entrance designated for temperature checks and check-in for staff, residents, and visitors. The smoke detectors and carbon monoxide detector were tested and were operational. LPA observed one (1) fire extinguisher in the kitchen to be fully charged and last serviced on 05-17-2021. LPA observed first aid kit and manual to be complete. The common living and dining areas are clean and properly furnished with seating, a table, and television for resident use. Facility currently has a working landline telephone. LPA observed nine (9) exit doors to have functioning auditory alarms when opened. All bedrooms, bathrooms, kitchen, and common areas windows have clean window coverings with screens and in good repair. Appliances in the kitchen were clean and all appeared functional. LPA observed emergency food and water for residents and staff. Facility has two (2) refrigerators that are fully stocked. LPA observed a sufficient supply of non-perishable and perishable foods. LPA observed a laundry room with a locked cabinet where detergent, harsh chemicals, and cleaning supplies are stored. Medication is stored in a locked cabinet adjacent to the kitchen. LPA observed one designated drawer next to the refrigerator where knives and sharps are locked and inaccessible to residents. LPA reviewed facility records at 11:05 am. Staff and resident files are in order and are kept locked in a cabinet adjacent to the kitchen. Hallways were free of any obstruction. (...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: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

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: 451 COLUMBIA LLC	FACILITY NUMBER: 565850187
	VISIT DATE: 09/28/2021

NARRATIVE

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(...Continued from LIC 809...)

There are six (6) resident bedrooms that were properly furnished. LPA observed all bedrooms to have a bed with clean linens, a nightstand, and adequate lighting. There are three (3) bathrooms for resident use. Bathrooms were measured for hot water, first bathroom measured at 105.8 degrees Fahrenheit, second bathroom measured at 105.4 degrees Fahrenheit, and third bathroom measured at 107.6 degrees Fahrenheit. Each bathroom was adequately equipped with toilet paper and paper towels, as well as grab bars and non-skid mats. LPA observed a covered patio area with patio furniture, a table, and chairs for resident use. LPA observed two (2) fence gates that self-latch for resident use in case of an emergency. No large bodies of water accessible to residents. LPA observed CDSS PINs, Emergency Exit Plan and necessary posters posted in the hallway easily accessible to residents. No firearms or ammunition will be stored in the facility at any time.

Facility is in compliance with Title 22 Regulations at this time. The CAB Analyst will notify the applicant when the license has been approved. Exit interview conducted. A hard copy 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: 09/28/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2021

LIC809 (FAS) - (06/04)

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