<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850512
Report Date: 10/18/2024
Date Signed: 10/18/2024 03:51:34 PM

Document Has Been Signed on 10/18/2024 03:51 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: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: 3DATE:
10/18/2024
TYPE OF VISIT:Post LicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:09 AM
MET WITH:Nicolle AlexTIME VISIT/
INSPECTION COMPLETED:
02:15 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) Kelly Dulek conducted an unannounced Post-Licensing Inspection. LPA arrived at 09:09AM and met with Program Director Nicolle Alex. Entrance interview conducted.

LPA, along with Program Director, toured the physical plant beginning at 09:17AM to ensure client health and safety and the facility is in compliance with Title 22 regulations. The following was observed:

Fire extinguishers were observed throughout the facility; all were observed to be fully charged and last serviced 03/19/2024.

SURROUNDING GROUNDS: The Front Yard includes a driveway, walkways and landscaped areas. The backyard includes both paved and landscaped areas, a patio, furniture appropriate for outdoor use, shaded area, as well as an in ground pool, which is kept fully enclosed with a locked fence. Program Director stated that all staff are water safety certified and the the pool is only utilized by clients while under direct staff supervision. There is an outdoor building, which includes a group room and locked storage area. All passageways were observed to be clear and free from hazard.

COMMON AREAS: These include the living room, dining room, and meditation/sitting room. In the common areas, walls, flooring and furniture was observed and all were in good condition at the time of the visit. There is a fireplace in the living room which was observed to be disabled.

KITCHEN: Appliances and fixtures appeared clean and functional. There was sufficient perishable and non-perishable food and water supply to accommodate a maximum capacity of 6 Clients. Knives and other sharps were observed to be locked in the chef pantry. Cleaning supplies were observed in a locked under-sink cabinet. Adjacent to the kitchen is the facility's laundry room. Laundry room contains locked chemical cabinet.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
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: 10/18/2024
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
26
27
28
29
30
31
32
GARAGE: Lower level attached garage was observed to be locked. Garage is utilized as a staff office and medication room. Medications are locked inside the locked garage. Facility vehicle was observed parked in front of the facility. Facility vehicle appeared to be in operable condition and is regularly maintained.

TREATMENT/THERAPY, MEDICATION ROOM & OFFICE AREAS: There is a Group Room and therapy room and medication room/office in the locked garage.

BEDROOMS: There are 4 (four) Bedrooms, all of which are designated for client use; 2 (two) are designated for shared client use and 2 (two) are designated as private client rooms. All bedrooms were observed and contained appropriate furniture, bedding and linens.

BATHROOMS: There are 3 (three) total Bathrooms, 1 (one) is designated as a private client restroom, 1 (one) is a shared client restroom and 1 (one) is designated for staff/guests. All restrooms were supplied with appropriate paper and hygiene products. Water temperature was measured in the shared client bathroom and measured within the required range at the time of the visit.

STAFF/CLIENT FILE REVIEW: LPA reviewed 5 (five) staff records during today's visit. All staff files were complete and contained all documents. LPA reviewed 3 (three) client file records during the visit, which were observed to be complete.

MEDICATIONS: The facility contains first aid kits throughout the facility. First aid supplies were observed to be complete. LPA observed medications for 2 clients, which were administered and documented in compliance with regulation.

INFECTION CONTROL/DISASTER PREPAREDNESS: During today’s visit, the LPA reviewed the facility's infection control policy and disaster preparedness policies. All items reviewed were in compliance, disaster plan is updated annually. Last disaster drill was conducted on 07/28/2024.

INTERVIEWS: During today's visit, LPA interviewed 2 (two) staff.

No citations issued. Exit interview conducted. Today’s report was reviewed and provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 3