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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850367
Report Date: 09/19/2024
Date Signed: 09/19/2024 02:30:51 PM

Document Has Been Signed on 09/19/2024 02:30 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 INCFACILITY NUMBER:
565850367
ADMINISTRATOR/
DIRECTOR:		AGGARWAL, RASHITAFACILITY TYPE:
740
ADDRESS:415 EAST SIDLEE STREETTELEPHONE:
(805) 418-7514
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 4DATE:
09/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:49 AM
MET WITH:Rashita Aggarwal & Connie RoushTIME VISIT/
INSPECTION COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced at 09:49AM to conduct an annual inspection. LPA initially met with facility staff. Administrator & Facility Designee were contacted via telephone. Designee Connie Roush arrived at 10:00AM, Administrator arrived shortly thereafter. Entrance interview conducted.

Beginning at 10:06AM, the LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher was observed to be fully charged and purchased 01/19/2024. Hardwired combination smoke and carbon monoxide detectors and fire door were tested at 01:02PM. Fire door did not close properly during test. LPA advised that the fire door shall remain closed at all times until the latch is repaired. All other systems were functional at the time of the visit.

KITCHEN: Kitchen knives are stored locked and inaccessible to residents in care. The supply of perishable and nonperishable food and emergency food and water supply is adequate. Appliances in the kitchen were clean and appeared functional.

BEDROOMS: There are (6) six bedrooms in the facility; the facility has 6 (six) private bedrooms for resident use. Lighting in the rooms appeared adequate. All resident rooms contained the appropriate furnishings and linens.

BATHROOMS: There are (2) two full bathrooms in the hallways. There are (1) private 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 measured at 139.4 degrees Fahrenheit at 10:14AM in the bathroom near bedroom #1. Hot water temperature measured at 135.3 degrees Fahrenheit at 10:23AM in the hallway bathroom. Hot water was not measured in the private resident restroom.


Continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/19/2024
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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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: 09/19/2024
NARRATIVE
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LAUNDRY/GARAGE: 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.

COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. 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.

FILES: Beginning at 10:35AM, LPA observed 4 (four) resident files for items including but not limited to physician's report, physician's orders, needs and service appraisals, and personal rights. All resident files were in order. LPA observed 4 (four) staff files for items including but not limited to health screening, TB test, criminal record clearance, and training records. Staff #1 (S1) was observed to be employed since April 2024 and did not have a valid fingerprint background clearance.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: The facility has an infection control plan and emergency disaster plan; both of which were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last drill documented on 08/02/2024.

MEDICATIONS: Medications are stored in a locked cabinet in the facility kitchen. The first aid supplies were complete, including a first aid manual. At 12:40PM, medications for 2 (two) residents were observed. Medications for both residents were observed to be properly stored and documented per regulation.

INTERVIEWS: During today's visit, LPA conducted interviews with both staff and residents. No concerns were noted during interviews.

Pursuant to Title 22, California Code of Regulations (CCR) and/or California Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D). Civil penalty issued in the amount of $500.

Exit interview was conducted. A copy of the report and Appeal Rights were reviewed and provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/19/2024
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/19/2024 02:30 PM - It Cannot Be Edited


Created By: Kelly Dulek On 09/19/2024 at 01:18 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: COLONY OF THOUSAND OAKS AT SIDLEE EAST INC
FACILITY NUMBER: 565850367

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/19/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as the water temperature measured at 139.4 degrees Fahrenheit in the bathroom near room #1 and 135.3 degrees Fahrenheit in the main hallway bathroom, which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/30/2024
Plan of Correction
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Water temperature was adjusted during today's visit and was measuring within the appropriate range. Licensee agreed to record water temperatures at varying times of the day for a 7-day period and submit the water temperature log to CCL by POC due date.
Type A
Section Cited
HSC
1569.17(c)(1)(A)
Licensing
(c)(1)(A) Subsequent to initial licensure, a person specified in subdivision (b) who is not exempted from fingerprinting shall obtain either a criminal record clearance or an exemption, pursuant to subdivision (f) of this section or Section 1522.7, from the State Department of Social Services prior to employment, residence, or initial presence in a facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as 1 staff (Staff #1 - S1) did not have a fingerprint background clearance and has been employed since April 2024, which poses an immediate safety and personal rights risk to persons in care.
POC Due Date: 09/19/2024
Plan of Correction
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During the visit, S1 was replaced with another staff. LPA provided Licensee a copy of the Guardian User Access Form. Licensee agreed to ensure the error with S1's fingerprints is remedied and Licensee will verify S1's fingerprint clearance associated to the facility prior to S1 returning to work. Licensee will submit proof of clearance to CCL when S1 is cleared.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Kelly Dulek
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2024


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