565850367-8-30-2023-29-AS-ECAS-CV7T2Y-20230830142130

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850367
Report Date: 08/30/2023
Date Signed: 08/30/2023 02:22:18 PM

Document Has Been Signed on 08/30/2023 02:22 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:	COLONY OF THOUSAND OAKS AT SIDLEE EAST INC		FACILITY NUMBER:	565850367
ADMINISTRATOR:	AGGARWAL, RASHITA		FACILITY TYPE:	740
ADDRESS:	415 EAST SIDLEE STREET		TELEPHONE:	(805) 418-7514
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 6	DATE:	08/30/2023
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	01:15 PM
MET WITH:	Connie Roush		TIME COMPLETED:	02:30 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	Licensing Program Analyst (LPA) Elsie Campos arrived at the facility announced at 1:15 p.m. to conduct a pre-licensing inspection. LPA met with Administrator Connie Roush. This is a change of ownership application from Colony of Thousand Oaks at Sidlee East Inc. (#565850258) to Colony of Thousand Oaks at Sidlee East, Inc. (#565850367). The current census is six for (6) residents, the facility currently has six (6) residents. The fire clearance was granted on 07/21/2023; in which all rooms were cleared for bedridden residents. Component III was waived as the applicant currently operates three other Residential Care Facilities for the Elderly (RCFE)’s that are currently in good standing. Applicant has attended Component III in the past and is RCFE administrator certified. At 1:20 p.m., the LPA toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. BEDROOMS: There are (6) six bedrooms in the facility; the facility has (4) four private bedrooms for resident use, one (1) shared bedroom for resident use and (1) one staff room. Staff room is kept locked. Room #1 and #5 have direct access to the outside. Lighting in the rooms appeared adequate. (5) five out of (5) five resident rooms and (1) one staff room were set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. BATHROOMS: There are (2) two full bathrooms in the hallways. There are (1) private bedroom bathroom for resident use. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between 110.6 – 118.5 degrees Fahrenheit. Continued on LIC 809-C.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COLONY OF THOUSAND OAKS AT SIDLEE EAST INC	FACILITY NUMBER: 565850367
	VISIT DATE: 08/30/2023

NARRATIVE

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COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hardwired; the smoke detectors were operable at the time of the visit. There are (4) four fire extinguishers which were fully charged and last serviced 11/8/2022. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted at the entrance area wall. Other required postings are also posted in the entrance area wall and dining room wall.

KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer on the left hand side of the stove. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and appeared functional. There is an adequate supply of emergency food. MEDICATIONS: Medications are in a locked cabinet in the kitchen. The first aid supplies were complete, including a first aid manual. FILES: Resident and staff records are locked and stored in a kitchen cabinet. LAUNDRY: The laundry area is locked and located in the attached garage to the right of the facility. Laundry detergent and chemicals are stored inaccessible. EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There are no bodies of water noted on the premises.The back and sides of the house are separated from the front yard by gates at the north and south side passageways the gate has a functioning self-latching mechanism for exit. There is no front yard gate or driveway gate. There are no other structures on the property. INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized
Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license.

Exit interview conducted and report issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 08/30/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/30/2023

LIC809 (FAS) - (06/04)

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