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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197609632
Report Date: 08/31/2023
Date Signed: 08/31/2023 02:53:39 PM

Document Has Been Signed on 08/31/2023 02:53 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:RESERVE AT THOUSAND OAKS, THEFACILITY NUMBER:
197609632
ADMINISTRATOR:SPENCER, ELIZABETHFACILITY TYPE:
740
ADDRESS:3575 N. MOORPARK ROADTELEPHONE:
(805) 492-2471
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 170CENSUS: 131DATE:
08/31/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Elizabeth Spencer TIME COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced Case Management - Incident inspection. At 1:06 p.m., LPA met with the Executive Director (ED), Elizabeth Spencer and explained the reason for the visit.

On 08/23/2023, the facility submitted a Report of Suspected Dependent Adult/Elder Abuse, where it was alleged that Resident #1 (R1) had engaged in a sexual relationship with Staff #1 (S1). An interview was conducted with the ED at 1:12 p.m. At 1:34 p.m., the LPA obtained copies of pertinent documents. At 2:45 p.m., the LPA along with the ED conducted a brief physical plant tour.

No immediate health and safety concerns were observed during today's inspection.

Further investigation is needed. Exit interview conducted. A copy of the report was provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Emily Peraldi
LICENSING EVALUATOR SIGNATURE: DATE: 08/31/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/31/2023
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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