565850188-9-24-2021-29-AS-MGCZ-C76NJW-20210924103101

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850188
Report Date: 09/24/2021
Date Signed: 09/24/2021 10:31:47 AM

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:	2592 CIRO LLC		FACILITY NUMBER:	565850188
ADMINISTRATOR:	SHERMAN, GILLIANA		FACILITY TYPE:	740
ADDRESS:	2592 CIRO AVE		TELEPHONE:	(805) 807-0663
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	09/24/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Gilliana Sherman		TIME COMPLETED:	10:30 AM

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 this property at 8:00am on 09-24-2021 and met with Licensee Gilliana Sherman. Entrance interview conducted. The applicant has obtained fire clearance for a total capacity of 6 (six) bedridden clients. Facility currently has five (5) residents of which only one (1) is bedridden. Facility has five (5) bedrooms and 2 bathrooms. Two (2) bedrooms are double occupancy and two (2) bedrooms are single occupancy. Fifth bedroom is for staff. 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 on May 17, 2021. The facility has emergency lighting throughout the hallways. LPA observed two (2) first aid kits, one in the living room and the other in the medication cabinet. Both had manual and were complete with alcohol wipes, ice packs, bandages, scissors, tweezers, gauze, and a thermometer. The common living and dining areas are clean and properly furnished with seating, coffee table and a television for resident use. LPA observed three (3) residents seating in the living room watching television. Facility currently has a working landline telephone. All seven (7) exit doors have functioning auditory alarms. 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 two (2) refrigerators, one in the kitchen and one in the garage. LPA observed a sufficient supply of at least seven (7) non-perishable and two (2) days perishable foods. Hot water at the kitchen sink measured at 118.3 degrees Fahrenheit. LPA observed a locked cabinet in the garage and in the hallway where chemicals and cleaning supplies are stored. Also, one designated drawer next to the kitchen sink was observed locked, containing knives and sharps. LPA observed medications to be locked in cabinet next to the refrigerator in the kitchen. Facility records are locked in a cabinet by the dining area. Hallways were free of any obstruction. There are four (4) resident bedrooms that were properly furnished. Single occupancy bedrooms had a bed with clean linens, a table lamp, a nightstand, and adequate lighting. Double occupancy bedrooms had two beds, clean linens, each side had a table lamp, a nightstand, and adequate lighting throughout. (...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: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

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: 2592 CIRO LLC	FACILITY NUMBER: 565850188
	VISIT DATE: 09/24/2021

NARRATIVE

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

There are two (2) bathrooms for resident use. Bathrooms were measured for hot water, first bathroom measured at 106.00 degrees Fahrenheit, second bathroom measured at 105.1 degrees Fahrenheit. Each bathroom was adequately equipped with toilet paper and paper towels, as well as with grab bars and non-skid mats. LPA observed a covered patio area with tables and chairs for resident use. LPA observed rails throughout the backyard for residents. LPA observed two (2) fence gates that self-latch with clear passageways for emergency exit use. LPA observed no bodies of water accessible to residents. LPA observed CDSS PINs posted along with Personal Rights, Complaint Poster (PUB 475), LTCO Poster, and Emergency Exit Plans. No firearms or ammunition will be stored in facility at any time.

Comp III was completed in conjunction with the visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA recommendation for licensure.

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: 09/24/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2021

LIC809 (FAS) - (06/04)

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