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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850522
Report Date: 08/21/2024
Date Signed: 08/22/2024 05:38:16 PM


Document Has Been Signed on 08/22/2024 05:38 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:SELECT SENIOR LIVING IVFACILITY NUMBER:
565850522
ADMINISTRATOR:HULL, DYLANFACILITY TYPE:
740
ADDRESS:128 ERTEN STREETTELEPHONE:
(805) 777-3855
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 0DATE:
08/21/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
12:00 PM
MET WITH:Dylan Hull and Tracy VarnellTIME COMPLETED:
01:45 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a Pre-licensing visit. Upon arrival LPA met with Applicant representative Dylan Hull and Administrators Tracy Varnell, Kathleen Leiterman, Kim Anderson. Administrators share duties and responsibilities at all 3 facilities. Applicant currently operates three other licensed facilities therefore Component III was waived for applicant. Fire Clearance for this facility is approved for six (6) non-ambulatory rooms, of which one (1) may be bedridden. The facility has a hospice waiver for six (6). Upon arrival a tour of the physical plant was conducted with Dylan Hull and Tracy Varnell; the LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. New complete first-aid kit observed; facility has adequate linen, water, nonperishable food supplies. Facility has six (6) non-ambulatory client bedrooms, two (2) staff rooms, four (4) full resident bathrooms, one (1) staff bathroom and a guest bathroom. One resident bedroom was observed staged with all required furniture during todays visit. Hot water temperature measured in residents bathroom which measured between 113 and 115 degrees Fahrenheit. Resident bathrooms observed with grab bars and non-skid shower floor. The kitchen, dining and living areas observed appropriately furnished. There are no bodies of water on the premises. Facility has working alarms on all exits and Smoke/Carbon Monoxide detectors. All medications, chemicals and sharp objects are in locked cabinets/drawers. Laundry area observed with washer and dryer. Backyard is completely fenced and gated. There is a covered area in the backyard for outdoor activities. The backyard is currently undergoing landscaping. Mr. Hull stated that the landscaping should be finished soon. LPA observed the detached garage under construction/upgrading to an office space for Administrators. Garage was observed to have a lock and Mr. Hall ensured that this area will be kept inaccessible to residents until the work is complete. The side of the house observed with landscaping and lumber supplies. This area should be cleared prior to licensure. Mr. Hull agreed to clear out the area and submit photos. Upon receipt of the photos LPA will forward the report to the CAB analyst. Applicant will be notified by the CAB Analyst when 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 and copy of report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 08/21/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/21/2024
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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