565850187-9-26-2022-29-AS-MARO-CJMSMY-20220926140042

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850187
Report Date: 09/26/2022
Date Signed: 09/26/2022 02:01:43 PM

Document Has Been Signed on 09/26/2022 02:01 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:	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:	09/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:25 PM
MET WITH:	Bernardito Suarez		TIME COMPLETED:	02:00 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), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 12:25 p.m. This will be the first Annual from their Pre-Licensing visit on 9/28/2021. Upon entering the facility, the LPA observed two (2) staff and two (2) visitors inside the facility not wearing face coverings/masks. LPA advised Administrator face covering/masks should be worn inside the facility at all times by facility staff and all visitors. The LPA was screened at the door by caregiver, Jeffrey Mateo and met with Administrator, Bernardito Suarez shortly after and the reason for the visit was explained. Entrance interview.

At 12:30 p.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area 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 seven (7) days perishable and two (2) days non-perishable food. The LPA observed one designated drawer in the kitchen where knives and sharps are locked and inaccessible to residents. Medications and facility files are locked in a cabinet adjacent to the kitchen. 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 throughout. Bathrooms were measured for hot water, the first bathroom measured at 105.2 degrees Fahrenheit at 12:32 p.m., the second bathroom measured at 107.6 degrees Fahrenheit at 12:34 p.m., and the third bathroom measured at 109.0 degrees Fahrenheit at 12:35 p.m.. …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: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

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 4

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: 09/26/2022

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...

GARAGE AND GROUNDS: The garage is locked and attached to the house. Cleaning supplies and chemicals are stored and inaccessible to residents. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit. COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed three (3) residents in the dining room having lunch. INFECTION CONTROL: 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, symptoms of COVID-19, and 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) 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. All staff and residents are fully vaccinated and boosted. No identified staffing concerns.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

Page: 2 of 4

Document Has Been Signed on 09/26/2022 02:01 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 09/26/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87469.1(a)(2)

Personal Rights of Residents in All Facilities (a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations... This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation, the licensee did not comply with the section cited above as two (2) staff and two (2) visitors were observed not wearing masks/face coverings in common areas, which poses an immediate health, safety, and personal rights risk to persons in care.
	POC Due Date: 09/26/2022
	Plan of Correction
1 2 3 4	The Administrator has agreed to immediately notify all staff to wear masks at all times in the facility. POC has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

Page: 3 of 4