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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850512
Report Date: 06/19/2024
Date Signed: 06/19/2024 06:16:17 PM

Document Has Been Signed on 06/19/2024 06:16 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:ELEMENTAL HEALTHFACILITY NUMBER:
565850512
ADMINISTRATOR/
DIRECTOR:		DOBBS, SHANNONFACILITY TYPE:
772
ADDRESS:145 ERTEN ST.TELEPHONE:
(805) 857-6449
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 0DATE:
06/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:22 PM
MET WITH:Shannon Dobbs and Nicole AlexTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a Pre-Licensing Inspection with Applicant Representatives Shannon Dobbs and Nicole Alex. An Application to operate a Social Rehabilitation Facility (SRF) was received by Community Care Licensing (CCL) on 03/09/2024. A Fire Clearance was approved for a maximum capacity of six (6) ambulatory residents on 03/24/2024.

A tour of the physical plant was conducted beginning at 3:45PM and the following observed:

The property is a single family dwelling home; four (4) bedrooms and four (4) bathrooms. The physical plant consist of an open floor plan concept with kitchen, dining and living area; there are two (2) designated therapy rooms, one inside the home and one located in the backyard. There is no staff room therefore awake staff is required. There is a laundry area in the facility. Fire extinguishers were observed throughout the facility; all were observed to be fully charged and last serviced on 03/19/2024. Hardwired smoke and carbon monoxide detectors were tested and all were functional at the time of the visit. Staff office and storage space is on the lower level attached garage. Medications and records will be stored in the office locked cabinet. The first aid kit was observed to be complete.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient emergency food and water supply to accommodate a maximum capacity of 6 clients for approximately three (3) to seven (7) days. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 (six) clients. Applicants indicated knives and other sharps will be stored in locked and inaccessible to clients in care. BEDROOMS: All bedrooms had sufficient lighting; were equipped and supplied with appropriate furniture, bedding and linens. Emergency lighting observed in the hallway. BATHROOMS: Three (3) out of the four (4) bathrooms are designated for residents use. Bathrooms were supplied with appropriate hygiene products. SURROUNDING GROUNDS: The front yard includes a driveway, walkways and landscaped areas. Backyard observed with outdoor seating area, shaded area, as well as an in-ground pool. The pool is kept inaccessible to clients with the use of fencing and a locked gate. Also there is a higher level outdoor seating area for residents use above the group therapy room in the backyard. There were no visible hazards or discrepancies observed. (Continue to LIC809c).

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE: DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/19/2024
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: ELEMENTAL HEALTH
FACILITY NUMBER: 565850512
VISIT DATE: 06/19/2024
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COMPONENT II/COMPONENT III ORIENTATION: A Component II Orientation was completed with the Applicant Representatives on 05/29/2024 virtually on teams. A Component III Orientation was conducted with Applicant Representatives during today's visit.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the report was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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