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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850369
Report Date: 08/29/2024
Date Signed: 08/29/2024 04:06:05 PM


Document Has Been Signed on 08/29/2024 04:06 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:COLONY OF THOUSAND OAKS AT VENUS, INC.FACILITY NUMBER:
565850369
ADMINISTRATOR:AGGARWAL, RASHITAFACILITY TYPE:
740
ADDRESS:189 VENUS STREETTELEPHONE:
(805) 241-4523
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
08/29/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:37 AM
MET WITH:Rashita AggarwalTIME COMPLETED:
04:10 PM
NARRATIVE
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced at 10:37AM to conduct an annual inspection. LPA initially met with facility staff. Administrator & Facility Designee were contacted via telephone. Designee Connie Roush arrived at 10:47AM, Administrator arrived at 11:10AM. Entrance interview conducted.

At 10:52AM, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguishers throughout the facility were observed to be fully charged, but 2 (two) indicated were last serviced 10/08/2022; the third did not indicate a date purchased or date serviced. Facility management showed LPA there are new recently purchased extinguishers present in the facility garage, which will be exchanged for the ones inside. Hardwired smoke and carbon monoxide detectors and fire doors were tested at 02:35PM and were functional at the time of the visit.

BEDROOMS: There are 8 (eight) bedrooms in the facility; the facility has 6 (six) private bedrooms for resident use, and 2 (two) staff rooms. Both staff rooms are kept locked. All resident rooms were observed to contain adequate lighting, proper furnishings and linens.

BATHROOMS: The facility contains 4 (four) bathrooms; there are (2) two full bathrooms in the hallways. There are two (2) private bathrooms for resident use. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in all resident bathrooms were well under the required range, measuring between 71.6 and 72 degrees Fahrenheit. In the hallway bathroom on the left, cleaning supplies were observed unlocked under the sink. In
Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
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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Document Has Been Signed on 08/29/2024 04:06 PM - It Cannot Be Edited

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: COLONY OF THOUSAND OAKS AT VENUS, INC.
FACILITY NUMBER: 565850369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(27)
General Food Service Requirements
(b) The following food service requirements shall apply: (27) All kitchen areas shall be kept clean and free of litter, rodents, vermin and insects.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as both live and dead insects were observed in the kitchen areas, including the floor, pantry, and outside portion of the refrigerator, which poses an immediate health risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Licensee indicated pest control visited the facility last week. Proof of ongoing pest control and kitchen cleaning will be provided to CCL by POC due date.
Type A
Section Cited
CCR
87465(a)(4)
Incidental Medical and Dental Care Services
(4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above in 2 (two) of 2 (two) residents' medications observed did not have accurate start dates and medication counts did not reflect that medications are administered properly for both residents which poses an immediate health risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Facility Management indicated that CSMDR will be rewritten accurately immediately, including start dates and accurate prescription numbers. Additionally, staff who administer medications will be retrained on proper medication administration and documentation and proof will be provided to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2024 04:06 PM - It Cannot Be Edited

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: COLONY OF THOUSAND OAKS AT VENUS, INC.
FACILITY NUMBER: 565850369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the kitchen drawer containing sharps such as knives and scissors does contain a latch, but the latch was not functional, which poses an immediate safety risk to persons in care.
POC Due Date: 08/29/2024
Plan of Correction
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During today's visit, the sharps were moved to a locked drawer. Maintenance staff arrived later in the visit with new latches to replace the non-functional latch and showed the LPA proof of correction. POC cleared.
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as a bucket containing cleaning supplies was observed under the sink in one hallway bathroom and 2 bottles of air freshener were observed in the cabinet in another hallway bathroom, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/05/2024
Plan of Correction
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Items were secured in a locked location during today's visit. Training will be provided to all staff on accessible items and proof of training will be provided to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 3 of 9


Document Has Been Signed on 08/29/2024 04:06 PM - It Cannot Be Edited

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: COLONY OF THOUSAND OAKS AT VENUS, INC.
FACILITY NUMBER: 565850369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above, as hall closet door was off the track and falling, barbecue and a chair were observed in the outdoor walkway, fire extinguishers were outdated, and the outdoor gate latch is non-functional, which poses a potential health and safety risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Facility Management agreed to repair all items. During the visit, items were moved from the outdoor walkway. Proof of all items being cleaned up and repaired will be sent to CCL by POC due date.
Type B
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as water temperature measured at 72 degrees Fahrenheit and Facility Management indicated the water heater has been not functioning properly and needs replacing, which poses a potential health and personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Maintenance person temporarily repaired the water heater during today's visit and temperature increased prior to the end of the visit. Facility Management agreed to replace water heater as planned. Proof of correction will be sent to CCL by POC due date.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 08/29/2024 04:06 PM - It Cannot Be Edited

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: COLONY OF THOUSAND OAKS AT VENUS, INC.
FACILITY NUMBER: 565850369

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/29/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in as one resident was observed with adjustable bed rails engaged in the full bedrail position, but is not on hospice, which poses/posed a potential personal rights risk to persons in care.
POC Due Date: 09/12/2024
Plan of Correction
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Management agreed to switch the bed rails to only 1/2 bedrails rather than adjustable bed rails. Order for half bedrails was obtained during today's visit.
Section Cited
Care of Persons with Dementia
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 08/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 5 of 9


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: COLONY OF THOUSAND OAKS AT VENUS, INC.
FACILITY NUMBER: 565850369
VISIT DATE: 08/29/2024
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Continued from LIC 809

the common bathroom on the right of the facility, air freshener was observed in the cabinet, accessible to residents in care.

COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility does have a fireplace, which was adequately screened. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted at the entrance area wall. Other required postings are also posted in the entrance area wall and living room wall. Hall closet contains extra linens and the door was off the track and falling down.

KITCHEN: Kitchen knives are stored in a drawer on the left hand side of the stove, however at 11:04AM, the lock on the drawer was observed to be non-functional and knives were accessible to residents in care. The supply of perishable and nonperishable food is adequate. Appliances in the kitchen were clean and appeared functional. There is an adequate supply of emergency food. At 11:09AM, multiple dead bugs were observed throughout the kitchen area, as well as live bugs in the kitchen, dining room, and living room area.

LAUNDRY/GARAGE: The laundry area is locked and located in the hallway to the right of the facility. Laundry detergent and chemicals are stored inaccessible in the laundry room. Entry to the garage is through the laundry room, so is also locked and inaccessible to residents in care. Garage contained extra food, storage, and additional items.

EXTERIOR: The exterior passageways were obstructed with a barbecue and a recliner chair. Both were moved during the visit. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water noted on the premises. The back and sides of the house are separated from the front yard by gates. Exit gate on the side of the house was observed to be not self-latching at the time of the visit.

FILES: Beginning at 11:40AM, LPA observed 6 (six) resident files for items including but not limited to physician's report, physician's orders, needs and service appraisals, and personal rights. Resident #1 (R1) was observed with full bed rails, but did not contain an order, nor is R1 on hospice. LPA observed 5 (five)

Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
Page: 8 of 9
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: COLONY OF THOUSAND OAKS AT VENUS, INC.
FACILITY NUMBER: 565850369
VISIT DATE: 08/29/2024
NARRATIVE
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Continued from LIC 809-C

staff files for items including but not limited to health screening, TB test, criminal record clearance, and training records. All staff files observed were maintained in compliance with regulation.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: The facility has an infection control plan, which was observed to be complete but not updated annually. Emergency disaster plan is also complete, but not updated annually. Emergency disaster drills are conducted, with the last drill documented on 01/08/2024. Regulation requires emergency drills documented quarterly.

MEDICATIONS: Medications are in a locked closet at the entrance of the facility. The first aid supplies were complete, including a first aid manual. They were stored in the medication closet. At 01:43PM, medications for 2 (two) residents were observed. Start dates were either not listed or were not accurate on the Centrally Stored Medication and Destruction Record (CSMDR). For one resident (Resident #2 - R2) medications were written twice on the CSMDR with differing information including start date and prescription number. Medication count did not match the number of days elapsed from start dates indicated for either resident.

INTERVIEWS: During today's visit, LPA conducted interviews with both staff and residents. No concerns were noted during interviews.


Pursuant to Title 22, California Code of Regulations (CCR) and/or California Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D).

Exit interview was conducted. A copy of the report and Appeal Rights were reviewed and provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 08/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/29/2024
LIC809 (FAS) - (06/04)
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