565850198-9-27-2021-29-AS-ASMH-C79P6J-20210927110225

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850198
Report Date: 09/27/2021
Date Signed: 09/27/2021 11:03:12 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:	254 EAST SIDLEE LLC		FACILITY NUMBER:	565850198
ADMINISTRATOR:	SHERMAN, GILLIANA		FACILITY TYPE:	740
ADDRESS:	254 EAST SIDLEE STREET		TELEPHONE:	(818) 300-1401
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	09/27/2021
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	09:20 AM
MET WITH:	Gilliana Sherman		TIME COMPLETED:	11:00 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) Ashley Smith arrived announced at 9:20 a.m. for a pre-licensing inspection. The LPA met with applicant Gilliana Sherman. This is a change of ownership application from Thousand Oaks Home Care IV (#565800711) to 254 East Sidlee LLC (#565850198). The current census is at 5 residents. The fire clearance was granted on 08/30/2021; in which all rooms were cleared for non-ambulatory clients, in which a bedridden person is permitted in Bedroom #1. Applicant successfully completed Component II on 09/10/2021 and completed Component III on 09/24/2021 with LPA Marth Guzman Chavez. The LPA toured the physical plant areas inside and outside with applicants to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. KITCHEN: Kitchen knives are stored locked and inaccessible in the closet in the hallway. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and all appeared functional. There is an adequate supply of emergency food. The facility recently completed a kitchen remodel, in which appliances and cabinets were replaced. BEDROOMS: There are seven bedrooms in the facility; there are six private bedrooms for resident use, and one staff room. The staff room is kept locked. All rooms have direct access to the outside. Lighting in the rooms appeared adequate. Five out of six private resident rooms were set up with beds, night stands, lamps, chests of drawers, chairs and closet space. BATHROOMS: There are three full bathrooms and one 1/2 bathroom. There are two (2) bathrooms for resident use; the half bathroom in the hallway and the full bathroom next to the staff room is designated for staff and guests. One out of the six resident rooms have an attached bathroom, and the other resident bathroom is in the hallway.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

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: 254 EAST SIDLEE LLC	FACILITY NUMBER: 565850198
	VISIT DATE: 09/27/2021

NARRATIVE

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BATHROOMS (CONT): The bathtubs are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature measured in the two hallway bathrooms between 110.5 – 112.7 degrees Fahrenheit.

COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. The facility smoke alarm system is hard wired; the smoke detectors and carbon monoxide detectors were operable at the time of the visit. There is a fireplace in the living room, which is appropriately screened. The fire extinguisher was fully charged and last serviced 05/17/2021. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted throughout the facility. Emergency telephone numbers are posted in the kitchen. Other required postings are posted in the hallway upon entry into the facility

MEDICATIONS: Medications are in a locked cabinet adjacent to the kitchen. First aid kits were complete.

FILES: Staff and resident files are stored locked and inaccessible in the medication cabinet. All resident and three staff files were reviewed at 9:40 a.m. and all records were in order.

LAUNDRY: The laundry area is in the hallway, directly across from the designated staff room and bathroom. Laundry detergent and chemicals are stored inaccessible in a cabinet.

GARAGE AND GROUNDS: The garage is locked and attached to the house. An additional refrigerator is in the garage with perishable items in good condition. The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water on the premises at the time.

INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents and visitors. The facility has 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.

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 and report issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 09/27/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/27/2021

LIC809 (FAS) - (06/04)

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