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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 421702848
Report Date: 04/24/2024
Date Signed: 04/24/2024 01:57:15 PM


Document Has Been Signed on 04/24/2024 01:57 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:COVENANT LIVING AT THE SAMARKANDFACILITY NUMBER:
421702848
ADMINISTRATOR:DANIELLE TERVO-SHIFFMANFACILITY TYPE:
741
ADDRESS:2550 TREASURE DRIVETELEPHONE:
(805) 687-0701
CITY:SANTA BARBARASTATE: CAZIP CODE:
93105
CAPACITY:379CENSUS: 317DATE:
04/24/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:50 AM
MET WITH:Scott BiglerTIME COMPLETED:
02:15 PM
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Licensing Program Analyst (LPA) Rankin and Licensing Program Manager (LPM) Burley conducted an unannounced visit to the facility to conduct the facility annual inspection. LPA met with Scott Bigler, and explained the purpose of the visit.

A tour of the inside and outside of the facility was conducted with Scott Bigler. The following was inspected and noted during the annual visit:

Physical Plant & Environment Safety: The facility is a large CCRC campus with independent living, assisted living, and memory care. The facility is clean, safe and sanitary, and in good repair. The facility has smoke and carbon monoxide detectors functioning. Fire extinguishers were fully charged. The lighting and lamps are sufficient, and facility is well lit inside and outside for safety. The showers have non-skid flooring. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The pathways are clear of any obstructions. Disinfectants, cleaning solutions and poisons are inaccessible to residents. The facility has sufficient space inside and outside for activities and visiting. The facility has outdoor areas for client use with furniture and plenty of shade. The facility has telephone and internet service for resident use.
Review of medication records was initiated but not completed.
Due to time constraints, LPA concluded the inspection. LPA will return to continue the annual inspection at a later date.
Exit interview, report read and report provided.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Melisa RankinTELEPHONE: (805) 635-4718
LICENSING EVALUATOR SIGNATURE:
DATE: 04/24/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/24/2024
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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