565850372-10-3-2023-29-AS-ECAS-CW9TML-20231003145120

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850372
Report Date: 10/03/2023
Date Signed: 10/03/2023 02:51:50 PM

Document Has Been Signed on 10/03/2023 02:51 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:	HOMELIFE SENIOR LIVING 5		FACILITY NUMBER:	565850372
ADMINISTRATOR:	NAZARI, SHERRY		FACILITY TYPE:	740
ADDRESS:	350 ARCTURUS ST		TELEPHONE:	(805) 338-4448
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 0	DATE:	10/03/2023
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	12:30 PM
MET WITH:	Devora 'Debbie' Leventer		TIME COMPLETED:	03:05 PM

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) Elsie Campos arrived at the facility announced at 12:30 p.m. to conduct a pre-licensing inspection. This application is for Homelife Senior Living 5 (#565850372). The LPA met with Administrator Devora ‘Debbie’ Leventer. Rooms are cleared for all bedridden residents. The fire clearance was granted on 6/21/2023; in which bedridden residents are permitted in Bedrooms B-G. Component III was waived as the applicant has attended Component III in the past and is RCFE administrator certified. At 12:45 p.m., the LPA toured the physical plant areas inside and outside with the Administrator 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 a drawer at the kitchen island. The supply of nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and functional. There is an adequate supply of emergency food and water. The facility recently completed a full home repaint and replaced furniture and kitchen supplies. BEDROOMS: There are (7) seven bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (1) one room that is used as staff office and to store files. The staff room is kept locked. Rooms B-F have indirect access to the outside and Room G has direct access to the outside. Lighting in the rooms is adequate. (6) six out of (6) six private resident rooms were set up with beds, nightstands, lighting, chests of drawers, chairs and closet space. BATHROOMS: There are (7) seven full bathrooms. There are (6) six private bathrooms for resident use, the full bathroom at the entrance of the home next to Room A staff office is designated for staff and guests. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between 108.6 – 118.9 degrees Fahrenheit. Continued on LIC 809-C.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: HOMELIFE SENIOR LIVING 5	FACILITY NUMBER: 565850372
	VISIT DATE: 10/03/2023

NARRATIVE

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COMMON AREA: 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 living room has a covered fireplace. The facility smoke alarm system is hardwired; the smoke detectors were operable at the time of the visit. There are two (2) fire extinguishers which were fully charged and last serviced 6/12/2023. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted in the entrance area wall. Other required postings are also posted on the entrance area wall.
MEDICATIONS: Medications are kept in medication closet located in the main hallway and is kept locked with a self closing digital lock. The first aid supplies were complete, including a first aid manual.
FILES: Resident and staff records are stored in the locked staff/office room and locked medication closet.
LAUNDRY: The laundry area is in a locked laundry room located in the main hallway. Laundry detergent and cleaning supplies are stored inaccessible in the locked laundry room.
EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use located outside the living room entrance. There is common recreational area with additional covered patio area with furniture a putting green and bocce ball area for resident use. There are no bodies of water noted on the premises. There is no front yard gate the driveway gate is kept open. The garage is attached to the property and is used for additional storage. There are 3 other structures on the property which will be licensed individually as part of the same ownership.
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. This report will be sent to the Centralized
Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license.

Exit interview conducted and report issued.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie Campos	TELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:	DATE: 10/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/03/2023

LIC809 (FAS) - (06/04)

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