565850189-9-24-2021-29-AS-MGCZ-C76RKA-20210924130512

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850189
Report Date: 09/24/2021
Date Signed: 09/24/2021 01:06:07 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:	143 WEST SIDLEE LLC		FACILITY NUMBER:	565850189
ADMINISTRATOR:	SHERMAN, GILLIANA		FACILITY TYPE:	740
ADDRESS:	143 WEST SIDLEE STREET		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:	10:40 AM
MET WITH:	Gilliana Sherman		TIME COMPLETED:	01:05 PM

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Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an announced pre-licensing visit to this property at 10:40am on 09-24-2021 and met with Licensee Gilliana Sherman. 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 one (1) bedridden and four (4) non-ambulatory. Facility has seven (7) bedrooms and three (3) bathrooms. All six (6) resident bedrooms are single occupancy. Seventh 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 charge. LPA observed first aid kits and manual to be complete with bandages, scissors, tweezers, gauze, and a thermometer. 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. All nine (9) 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 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 next to the kitchen. LPA observed one designated drawer next to the refrigerator where knives and sharps are locked and inaccessible to residents. Facility records are locked next to the medication cabinet. Hallways were free of any obstruction. 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 measure for hot water, first bathroom measured at 111.2 degrees Fahrenheit, second bathroom measured at 107.6 degrees Fahrenheit, and third bathroom measured at 111.1 degrees Fahrenheit. Each bathroom was adequately equipped with toilet paper and paper towels, as well as grab bars and non-skid mats.

(...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: 143 WEST SIDLEE LLC	FACILITY NUMBER: 565850189
	VISIT DATE: 09/24/2021

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

LPA observed a covered patio area with patio furniture including two large chairs with cushions, a table and chairs for resident use. LPA observed two (2) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents. LPA observed CDSS PINs posted along with Personal Rights, Complaint Poster (PUB 475), 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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