565850195-10-28-2023-29-AS-SURA-CX2SCC-20231028134520

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850195
Report Date: 10/28/2023
Date Signed: 10/28/2023 01:46:05 PM

Document Has Been Signed on 10/28/2023 01:46 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	9 WEST SIDLEE LLC		FACILITY NUMBER:	565850195
ADMINISTRATOR:	SHERMAN, GILLIANA		FACILITY TYPE:	740
ADDRESS:	9 WEST SIDLEE ST		TELEPHONE:	(818) 300-1404
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	10/28/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:29 AM
MET WITH:	Mervin Galvez		TIME COMPLETED:	01:30 PM

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Licensing Program Analyst (LPA), Sandra Urena conducted an unannounced required annual inspection visit. The LPA was greeted by staff, and the LPA explained the reason for the visit. The Administrator Mervin Galvez arrived shortly thereafter.

The LPA and the administrator began the physical plant tour 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 (1) designated drawer in the kitchen where knives are locked and inaccessible to residents. Medications were observed locked in a cabinet adjacent to the kitchen.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are three designated client rooms and one staff room. There was a linen closet in the hallway with extra towels and linens.

RESTROOMS: 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. Three (3) common and one (1) private bathrooms’ water hot water was measured and were in compliance measuring between 105- and 120-degrees Fahrenheit.

.Continued on LIC 809C…

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: 9 WEST SIDLEE LLC	FACILITY NUMBER: 565850195
	VISIT DATE: 10/28/2023

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COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 70 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. One fire extinguisher was fully charged and were last serviced on 06/12/2023. The LPA observed required postings throughout the common space. The washer and dryer are adjacent to the kitchen area. All laundry materials are located in a locked cabinet and inaccessible to residents

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single-latched. No bodies of water noted. The garage is attached to the house and has a door by the front yard. The garage door was locked at the time of the inspection.

RECORDS: Records review began at 11:30 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 12:15 p.m.; medications are centrally stored and locked in a cabinet adjacent to the kitchen. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. 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 reviewed the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Fire drill
- Liability Insurance
No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra Lopez	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra Urena	TELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:	DATE: 10/28/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/28/2023

LIC809 (FAS) - (06/04)

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