565850372-9-20-2024-29-AS-KDUK-D9ARTF-20240920131816

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850372
Report Date: 09/20/2024
Date Signed: 09/20/2024 01:18:20 PM

Document Has Been Signed on 09/20/2024 01:18 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:	DEBBIE LEVENTER		FACILITY TYPE:	740
ADDRESS:	350 ARCTURUS ST		TELEPHONE:	(805) 338-4448
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 0	DATE:	09/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:20 AM
MET WITH:	Dvora (Debbie) Leventer		TIME COMPLETED:	01:20 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced at 10:20AM with the purpose of conducting a required annual visit. The LPA initially met with facility staff. Administrator Dvora "Debbie" Leventer was contacted via telephone and arrived shortly thereafter. Entrance interview conducted.

This facility has no residents in care at this time, and have not had residents in care since the date of licensure. Therefore, the physical plant areas were observed, however no files were observed and no interviews were conducted.

Beginning at 11:05AM, the LPA, along with Administrator, 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 extinguisher was observed to be fully charged and last serviced 06/03/2024.

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 a staff room. The staff room will be kept locked.

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 room) is designated for staff and guests. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms.

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.

GARAGE: The garage was observed to be locked and contain storage, a refrigerator and freezer.

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

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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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: 09/20/2024

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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. There is a functioning telephone on the premises. All required postings were observed on the entrance area wall. Emergency exiting plans/sketch are posted. Auditory alarms were observed on all exit doors.

KITCHEN: Appliances in the kitchen were clean and appeared functional. The facility has an adequate supply of non-perishable food and emergency food and water supply.

EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use. There are 3 (three) additional licensed facilities on the property. All 4 (four) facilities share a common recreation area with additional covered patio 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 and the driveway gate is kept unlocked.

RESIDENT & STAFF RECORDS: Records were not reviewed as there are no residents in care at this time.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. The facility's policies as it pertains to infection control are adequate. The facility's emergency disaster plan was observed to be complete and updated annually, as required.

MEDICATIONS: Medications were not observed, as there are no residents in care at this time.

INTERVIEWS: No interviews were conducted, as there are no residents in care at this time.

No citations issued. Exit interview conducted. A copy of today's report was provided.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2024

LIC809 (FAS) - (06/04)

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