565850725-8-10-2026-29-AS-EMOY-DWTV8W-20260810161326

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850725
Report Date: 08/10/2026
Date Signed: 08/10/2026 04:13:48 PM

Document Has Been Signed on 08/10/2026 04:13 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SUNRISE OF THOUSAND OAKS		FACILITY NUMBER:	565850725
ADMINISTRATOR/ DIRECTOR:	BRIAN LARIOS		FACILITY TYPE:	740
ADDRESS:	3680 N MOORPARK RD		TELEPHONE:	(805) 206-7860
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 158		CENSUS: 110	DATE:	08/10/2026
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Brian Larios - Executive Director (ED)		TIME VISIT/ INSPECTION COMPLETED:	04:20 PM

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Licensing Program Analyst (LPA) Erica Mosley arrived at the facility unannounced to conduct a post licensing visit and entered the facility at 10:00 a.m. LPA was greeted by front door receptionist and explained the reason for the visit. The LPA met with Executive Director (ED) Brian Larios and the reason for the visit was explained. Entrance interview conducted. LPA Mosley and the ED 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 facility is a four (4) story building that consists of a memory care unit, and an assisted living unit. There are fire sprinklers and fire doors throughout the facility. A physical plant tour was conducted inside and out. An approved fire clearance was received on 02/25/2026, clearing them for a capacity of 158, of which ten (10) may be bedridden, and 148 may be non-ambulatory. All rooms are approved for non-ambulatory and bedridden residents. An updated document of room numbers/locations of all bedridden residents shall be maintained and available for emergency responders upon request. Delayed egress is approved for the memory care unit. Age range 60 and over. Hospice care waiver approved for twenty five (25) residents.

Interviews: Starting at approx. 10:30 a.m. and throughout the visit LPA conducted random brief interviews with eight (8) residents and six (6) staff. Resident interviews revealed that no concerns were noted at the time of the visit. Staff interviews revealed that staff are knowledgeable in their job description, resident rights, different forms of abuse, and reporting procedures.

Report Continued on LIC 809C...

Kasandra Lopez
Erica Mosley
	DATE: 08/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE OF THOUSAND OAKS	FACILITY NUMBER: 565850725
	VISIT DATE: 08/10/2026

NARRATIVE

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(PAGE 2) REPORT CONTINUED FROM LIC 809...
Common Areas: These included the beauty salon, activity room, fitness center, bistro, and dining areas in assisted living and memory care units. The common areas were checked for cleanliness and furniture was checked for functionality during time of visit. Fireplaces were properly screened. LPA observed designated storage / utility rooms with emergency food and water. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. There are fire extinguishers throughout the facility that were fully charged and were last serviced 05/11/26. The LPA observed required postings throughout the common space. The LPA observed the stairwells, and they each had an emergency evacuation chair at the fourth floor. Activity Rooms were observed and clean at the time of visit. LPA observed laundry rooms on all floors.

Bedrooms: Starting at 10:30 a.m. The LPA and ED observed fifteen (15) randomly selected resident bedrooms, of which three (3) were on each floor, thus three (3) were in memory care and twelve (12) were in assisted living. All resident bedrooms were properly furnished with at least one chair, nightstand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. All passageways were observed to be clear of obstructions.

Restrooms: The resident restrooms appeared clean and sanitary and in operating condition with grab bars and slip-resistant surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared in the private rooms. The hot water measured between 106.5 – 112.9 degrees Fahrenheit all within the required range.
Surrounding Grounds (Outdoors): The LPA observed appropriate outdoor furniture, with a covered shaded area for residents in both, the memory care unit courtyard and the assisted living courtyard. Parking is available for residents and visitors.
Kitchen: The LPA inspected the kitchen/food service area. Knives are stored and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) day perishable and seven (7) day non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates.
Report continued on LIC809-C PAGE 3...

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SUNRISE OF THOUSAND OAKS	FACILITY NUMBER: 565850725
	VISIT DATE: 08/10/2026

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(PAGE 3) REPORT CONTINUED FROM LIC 809-C PAGE 2...

Records: Resident Records and Personnel records were reviewed starting at approx. 12:35 p.m., Six (6) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. During the review LPA discovered that three (3) of the six (6) staff were not associated to the facility posing an immediate health and safety right risk to residents in care. At the time of the visit the Business Office Director began associating the staff to the facility. During file review LPA discovered an additional seven (7) staff not associated to the facility which poses an immediate health, safety and personal rights risk to persons in care.

Six (6) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files in order at the time of the visit.

Medication Audit: LPA conducted a medication review at approx. 2:25 p.m., LPA reviewed six (6) randomly selected resident centrally stored medication destruction record (CSMDR). The medications are centrally stored in the wellness room located on the third floor. Medications are labeled and checked for expiration dates. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. No errors observed during review.

Documents: Documents obtained during the visit include: Facility roster, Resident roster and emailed copy of the Limited Liability insurance.

At the time if the visit the LPA reviewed the facilities contact information on file including phone numbers, email and annual fees. ED updated the email on and confirmed that all information is accurate.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). A civil penalty in the amount of $5,000 was issued. Ten (10) staff were not associated to the facility, and each staff member had been working for more than five (5) days. The penalty was assessed at $500 per staff member, totaling $5,000 (10 x $500 = $5,000). ED was informed that failure to correct deficiencies may result in additional civil penalties. Exit interview conducted, report issued, and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Erica Mosley
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 08/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 08/10/2026 04:13 PM - It Cannot Be Edited

Created By: Erica Mosley On 08/10/2026 at 03:10 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: SUNRISE OF THOUSAND OAKS	FACILITY NUMBER: 565850725
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/10/2026

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 08/11/2026 Section Cited CCR 87355(e)(3)	1 2 3 4 5 6 7	(e) All individuals subject to a criminal record ... 1569.17(b) shall prior to working, ... in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:	1 2 3 4 5 6 7	At the time of the visit, the Business Office Director began associating the staff to the facility. The Executive Director will submit a letter confirming that all staff have been associated and will ensure that, moving forward, all staff are fully associated to the facility prior to the start of employment.
	8 9 10 11 12 13 14	Based on observation and record review, the licensee did not comply with the section cited above as ten (10) staff were not associated to the facility at the time of the visit which poses an immediate health, safety and personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

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

	Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:

	Erica Mosley
NAME OF LICENSING PROGRAM ANALYST:

LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 08/10/2026

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/10/2026

LIC809 (FAS) - (06/04)

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