<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405800577
Report Date: 08/28/2024
Date Signed: 08/29/2024 01:12:42 PM

Document Has Been Signed on 08/29/2024 01:12 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:VILLAGE AT SYDNEY CREEK, THEFACILITY NUMBER:
405800577
ADMINISTRATOR/
DIRECTOR:		LIZA HIXFACILITY TYPE:
740
ADDRESS:1234 LAUREL LANETELEPHONE:
(805) 543-2350
CITY:SAN LUIS OBISPOSTATE: CAZIP CODE:
93401
CAPACITY: 84CENSUS: 60DATE:
08/28/2024
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:46 AM
MET WITH:Liza Hix, AdministratorTIME VISIT/
INSPECTION COMPLETED:
03:45 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
On 8/28/24 at 10:46 am, Licensing Program Analyst (LPA) Rankin made an unannounced Case Management Annual Continuation visit to the facility above. LPA met with Liza Hix, Administrator, and explained the purpose of the visit.

Physical plant/Outdoor space were toured for a second time due to the size of the facility. The facility has two separate garden areas with nice walkways for residents to enjoy. The garden fountain is in compliance. Items noted as potential fall hazards were addressed and fixed to ensure client safety when walking the garden paths. Facility is in compliance with fire clearance.

Emergency Disaster Preparedness plan is current, and forms were posted. The facility provides disaster drills quarterly. The fire extinguishers were charged. The dual smoke and carbon monoxide detectors are present and hard wired throughout the facility and were in inspected this year by an outside company. Facility has an evacuation stair chair in Neighborhood 3 for the evacuation gate.



The Storage/Laundry Room have sufficient amounts of personal hygiene products which are provided by the licensee and all cleaning products, toxins are stored and locked away inaccessible to residents in care.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/28/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 6
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: VILLAGE AT SYDNEY CREEK, THE
FACILITY NUMBER: 405800577
VISIT DATE: 08/28/2024
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
26
27
28
29
30
31
32
Residents with Special Health Needs: The facility does accept dementia residents in care. All items that could pose a danger, sharps, cleaners were locked separately in cupboards. The facility has a license for 84 Non-Ambulatory which 84 may be bedridden. The facility does have delayed egress. The facility does have hospice and home health visits to the facility for residents in care.

Staff files: All required training is scheduled and trainer is up to date on requirements. Staff records were checked for expired or missing certificates and clearances: LPA conducted a file review of 6 staff for criminal record clearances/associations/and current First Aid. Records were complete.


Exit interview conducted, and the report printed and given to administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 08/28/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/28/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6