565850522-8-19-2025-29-AS-ZCHN-DKPUZZ-20250819160222

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850522
Report Date: 08/19/2025
Date Signed: 08/19/2025 04:06:31 PM

Document Has Been Signed on 08/19/2025 04:06 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 IV		FACILITY NUMBER:	565850522
ADMINISTRATOR/ DIRECTOR:	VARNELL, TRACY		FACILITY TYPE:	740
ADDRESS:	128 ERTEN STREET		TELEPHONE:	(805) 777-3855
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 5	DATE:	08/19/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:40 AM
MET WITH:	Dylan Hall and Kimberly Anderson		TIME VISIT/ INSPECTION COMPLETED:	04:00 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) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. Upon arrival, LPA met with staff and later with one of the Administrator, Kim Anderson. Reason for the visit was explained. At 10:45 a.m., the LPA along with the staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards. Facility is fire cleared for six (6) non-ambulatory rooms, of which one (1) may be bedridden. The facility has a hospice waiver for six (6). The LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. Facility has six (6) non-ambulatory resident bedrooms, one (1) staff room and one (1) room used for staff office/rest area. BEDROOMS: The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms observed appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. The staff bedroom and office/rest area observed locked during today's visit. BATHROOMS: There are six (6) total bathrooms, four (4) for resident use, one (1) for staff use and one for guests. All bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The hot water was measured within 105 - 120 degrees Fahrenheit. KITCHEN: Knives and sharps were observed in a locked drawer. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. COMMON AREAS: Furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature.(Continue to LIC809c).

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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: SELECT SENIOR LIVING IV	FACILITY NUMBER: 565850522
	VISIT DATE: 08/19/2025

NARRATIVE

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Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The last emergency disaster drill took place on 6/24/2025 and conducted every three months. Activities were observed in the common areas; required postings observed posted. Exit alarms and Smoke/Carbon Monoxide detectors observed operable during visit. STORAGE/ OUTDOORS: Storage areas observed locked and inaccessible at the time of visit. Fire extinguisher observed with purchase date 06/03/2025. An adequate supply of emergency food and water was observed. Sufficient supply of Personal Protectant Equipment (PPE) observed. Cleaning supplies and toxins observed in the storage area inaccessible to residents in care. Laundry area observed with washer and dryer. Detergents and other cleaning supplies stored inaccessible to residents. The backyard has a shaded area with furniture for resident use. The LPA observed two (2) gates that self-latches with a clear passageway in case of an emergency. Garage is converted into office space.

RECORDS: Records review began at 12:30 p.m., five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Resident files observed complete. Two (2) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Staff files observed complete. MEDICATIONS: Medications review began at approximately 2:25 p.m. Routine medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No medication errors observed at this time.

Following deficiency observed during today's visit: The licensee has retained a resident (R1) with a feeding tube. Interview with staff revealed that the facility care staff are responsible for providing meals, fluids, and medication through the G-tube for R1. Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D).

Exit interview conducted. Copy of the report provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/19/2025 04:06 PM - It Cannot Be Edited

Created By: Zabel Chochian On 08/19/2025 at 03:43 PM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SELECT SENIOR LIVING IV	FACILITY NUMBER: 565850522
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/19/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Request Denied

Type A

Section Cited

CCR

87633(j)(1)

Hospice Care for Terminally Ill Residents

(1) In caring for a resident's health condition, facility staff, other than appropriately skilled health professionals, shall not perform any health care procedure that under law may only be performed by an appropriately skilled professional. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, interview, and records review the licensee did not comply with the section cited above. Staff are responsible and providing meals, fluids, and medication to resident #1 through G-tube. This poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 08/20/2025
	Plan of Correction
1 2 3 4	Licensee stated they will contact hospice to manage R1's G-tube care at this time and submit an exception outlining the plan of care for managing R1's G-tube.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

	Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:

	Zabel Chochian
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/19/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/19/2025

LIC809 (FAS) - (06/04)

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