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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850221
Report Date: 09/30/2021
Date Signed: 10/01/2021 09:13:42 AM

Document Has Been Signed on 10/01/2021 09:13 AM - 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:GLEN PARK AT OJAIFACILITY NUMBER:
565850221
ADMINISTRATOR:PINK, TILLMAN JR.FACILITY TYPE:
740
ADDRESS:225 N LOMITA AVETELEPHONE:
(818) 296-4646
CITY:OJAISTATE: CAZIP CODE:
93023
CAPACITY: 48CENSUS: 20DATE:
09/30/2021
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:24 AM
MET WITH:Tillman Pink, Jr and Maria RothTIME COMPLETED:
02:21 PM
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Licensing Program Analyst (LPA) JoAnn Rosales made a Pre-licensing visit to the facility. LPA met with Administrator/Applicant Representative Tillman Pink, Jr and Assistant Administrator Maria Roth. This application is a change of ownership from At Home in Ojai #565801458. Component III was conducted in conjunction with this pre-licensing visit.

LPA inspected facility for Fire Safety, Personal Accommodations and Services, Medication Procedures, and Food Service. First-aid kit is complete, facility has adequate linen, water and nonperishable food supplies.

Facility has 1 private and 17 shared rooms, 3 shared and 15 private bathrooms on the 1st floor, 6 shared rooms, 2 shared and 2 private bathrooms on the 2nd floor. Signal system was tested and operable. The common areas were appropriately furnished and lighting was adequate. There is additional entertainment equipment and games for activities. Medications and resident records will be kept in a locked cabinet in the office. Staff records will be kept in a locked cabinet in the office. Hot water temperature tested at 115.9 and 118.8 degrees Fahrenheit in resident bathrooms during today’s visit. LPA observed smoke detectors and carbon monoxide detectors operating properly and fire extinguishers properly charged. Fire clearance is approved for 48 non-ambulatory of which 8 may be bedridden in bedrooms #E10, E11, E12 and E13.

The following needs to be completed/proof submitted prior to the facility being licensed:

1. Updated facility sketch consistent with physical plant.

Exit interview conducted, today's report was reviewed and emailed to the Administrator.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 09/30/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/30/2021
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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