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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850370
Report Date: 10/16/2023
Date Signed: 10/16/2023 03:47:53 PM

Document Has Been Signed on 10/16/2023 03:47 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 WEST INCFACILITY NUMBER:
565850370
ADMINISTRATOR:AGGARWAL, RASHITAFACILITY TYPE:
740
ADDRESS:171 WEST SIDLEE STREETTELEPHONE:
(805) 496-4541
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
10/16/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Connie RoushTIME COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility announced at 10:30 a.m. to conduct a
pre-licensing inspection and conducted a subsequent visit unrelated to the pre-licensing inspection at this facility. LPA met with Administrator Connie Roush. This is a change of ownership application from Colony of Thousand Oaks at Sidlee West, Inc. (#565850181) to Colony of Thousand Oaks at Sidlee West Inc. (#565850370). The current census is six for (6) residents, the facility currently has five (5) 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.

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 (8) eight bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (2) two staff rooms. Both staff rooms are kept locked. Room #4, #6 do not have direct access to the outside. Lighting in the rooms appeared adequate. (6) six out of (6) six private resident rooms and (2) staff rooms were set up with beds, nightstands, lamps, chests of drawers, chairs and closet space.

BATHROOMS: There is (1) half bath and (1) full bathroom in the hallway. There are two (2) private bedroom bathrooms for resident use; the half bathroom in the hallway is designated for staff and guests, the full bathroom in the hallway is designated 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 105.0 – 108.6 degrees Fahrenheit.

Continued on LIC 809-C.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE: DATE: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/16/2023
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 WEST INC
FACILITY NUMBER: 565850370
VISIT DATE: 10/16/2023
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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 two (2) 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 on the dining area wall and living 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 closet in the main hallway. The first aid supplies were complete, including a first aid manual.

FILES: Resident and staff records are stored in the medication closet.

LAUNDRY: The laundry area is located in the hallway to the right of the facility next to bedroom #1. Laundry detergent and chemicals are locked and stored inaccessible in the laundry room.

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 is a gated pool that was observed to be locked and inaccessible. The back and sides of the house are separated from the front yard by gates at the north and south-side passageways, both gates have self-latching mechanisms. 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: 10/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/16/2023
LIC809 (FAS) - (06/04)
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