565850198-10-21-2022-29-AS-MARO-CKESJB-20221021135452

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850198
Report Date: 10/21/2022
Date Signed: 10/21/2022 01:55:24 PM

Document Has Been Signed on 10/21/2022 01:55 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:	254 EAST SIDLEE LLC		FACILITY NUMBER:	565850198
ADMINISTRATOR:	SARREAL, JOVY		FACILITY TYPE:	740
ADDRESS:	254 EAST SIDLEE STREET		TELEPHONE:	(905) 807-0663
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 5	DATE:	10/21/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:20 PM
MET WITH:	Jovy Sarreal		TIME COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced visit to 254 East Sidlee LLC to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 12:20 p.m. This will be the first Annual from their Pre-Licensing visit on 9/27/2021. Upon arrival, the LPA was greeted and screened at the door by staff, Jeffrey Mateo. The Administrator, Jovy Sarreal was present at the facility and the reason for the visit was explained. Entrance interview.

At 12:22 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 (1) designated drawer in the kitchen where knives and sharps are locked and inaccessible to residents. Medications were observed locked in a cabinet adjacent to the kitchen. One (1) resident was observed in the kitchen having lunch during time of visit.

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. Three (3) resident bathrooms were measured for hot water and were in compliance measuring between 105- and 120-degrees Fahrenheit. …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: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

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: 10/21/2022

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…Report Continued from LIC 809...

GARAGE AND GROUNDS: The garage is locked and inaccessible to residents. The LPA observed one (1) additional refrigerator stocked at the time of visit. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Cleaning supplies and chemicals were observed in a locked cabinet by the laundry room. 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 one (1) resident in the living room watching television at the time of visit. Fire extinguisher was observed and charged on 6/07/2022.

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. 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 are fully vaccinated and boosted. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Exit interview conducted. No citations issued. Report was reviewed with Administrator and a copy 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: 10/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/21/2022

LIC809 (FAS) - (06/04)

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