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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850483
Report Date: 07/14/2025
Date Signed: 07/14/2025 03:40:42 PM

Document Has Been Signed on 07/14/2025 03:40 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:COLONY OF THOUSAND OAKS AT SIDLEE, INC.FACILITY NUMBER:
565850483
ADMINISTRATOR/
DIRECTOR:		AGGARWAL, RASHITAFACILITY TYPE:
740
ADDRESS:117 W SIDLEE STREETTELEPHONE:
(570) 290-3407
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 4DATE:
07/14/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:32 AM
MET WITH:Rashiya AggarwalTIME VISIT/
INSPECTION COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Trevor Byrne arrived at the facility unannounced to conduct a required annual visit at 11:32 AM. LPA met with facility staff who contacted facility Licensee Representative Dr. Rashiya Aggarwal and Administrator Eleanor Jimenez via telephone call. The Licensee Representative and the facility Administrator arrived to the facility at approximately 11:40 AM. Entrance interview conducted and the reason for the visit was explained.

Beginning at 11:40 AM, the LPA, along with the Licensee Representative and the facility Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

COMMON AREAS: This includes the living room, dining room, and hallways. LPA observed the living room to be clean and properly furnished at the time of the visit. The living room contains chairs, a television, and activities for resident use. Additionally, the living room was observed to contain an appropriately screened fireplace. The dining room was observed to be clean and contained adequate amounts of seating for resident use. The dining room contained a fire extinguisher. It was fully charged and last serviced on 10/03/2024. The hallway was observed to contain a storage cabinet that contained linens and additional care supplies. LPA observed all required postings for the facility located on the living room wall and hallway wall. Combination fire alarms and fire doors were tested at 12:20 PM and functioned properly at the time of inspection. LPA observed cameras throughout the common areas of the facility. The Licensee Representative confirmed that the cameras do not record audio.
Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/14/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COLONY OF THOUSAND OAKS AT SIDLEE, INC.
FACILITY NUMBER: 565850483
VISIT DATE: 07/14/2025
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BEDROOMS: There are eight (8) bedrooms in the facility; six (6) are a single occupancy resident rooms and two (2) are staff bedrooms. LPA the Licensee Representative and facility Administrator toured all eight (8) bedrooms. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Auditory alarms were observed on facility exits and were functioning at the time of inspection. The staff bedrooms were observed to be properly secured and inaccessible to clients in care.

BATHROOMS: There are five (5) bathrooms at the facility. Two (2) bathrooms are designated as shared/common resident bathrooms and three (3) are designated as a private resident bathrooms. All bathrooms were observed to be clean and in good repair and all were equipped with nonskid surfaces. One (1) shared bathroom was observed to contain an unsecured cabinet that contained Lysol disinfectant spray. LPA informed the Licensee Representative who secured the item at the time of the inspection. Grab bars were observed in resident showers and near resident toilets, all were properly secured. The water temperature was measured between 106.2 and 114.3 degrees Fahrenheit, which is within the range required by regulation.

KITCHEN/LAUNDRY: The LPA observed the kitchen area to be clean. Kitchen appliances were in operable condition. The facility has a sufficient supply of two (2) days perishable and seven (7) days non-perishable food. LPA observed a secured drawer to contain knives and other sharp objects. LPA observed the laundry to be located adjacent to the kitchen. LPA observed an un-secured cabinet in the laundry to contain detergents and extra cleaning supplies. LPA informed the Licensee Representative who secured the cabinet at the time of the inspection. Additionally, the Licensee Representative had a conversation with facility staff educating them of the importance of securing cleaning chemicals at the facility.



Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
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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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COLONY OF THOUSAND OAKS AT SIDLEE, INC.
FACILITY NUMBER: 565850483
VISIT DATE: 07/14/2025
NARRATIVE
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OUTDOOR SPACE: The facility has two (2) emergency exit gates located in the back yard on either side of the facility. All fences/railings located at the facility were secured properly. LPA observed clear passageways for emergency exit use. The facility has adequate shaded seating outdoors for resident use. LPA observed the backyard of the facility to contain a pool. LPA observed one (1) of two (2) gates to the pool to be unlocked and accessible to clients in care at the time of the inspection. LPA informed the Licensee Representative and the Administrator that an accessible body of water is a zero-tolerance violation and an immediate civil penalty in the amount of $500 will be assessed on today’s date (07/14/2025). The Licensee Representative and the Administrator stated that the pool cleaner did not lock the gate behind them after completing a pool cleaning. The Licensee Representative and the Administrator replaced the locks on the pool gate at the time of the visit and provided the key to staff to monitor the gate when future pool cleaning is conducted. Additionally, the Licensee Representative and the Administrator had a conversation with facility staff emphasizing the importance of ensuring bodies of water are not accessible to clients in care.

RECORD REVIEW: Record review began at 12:26 PM. Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, first aid certification, consent forms, and personal rights. Two (2) staff files were reviewed. All staff files contained the required documentation and trainings. Four (4) resident files were reviewed. One (1) resident’s admission agreement was observed to be printed on the front and back of the sheet of paper. LPA informed the Licensee Representative and the Administrator that per Title 22 regulations all print in admission agreements shall appear on one side of the paper only. The Licensee Representative and the Administrator expressed understanding and agreed to re-print the admission agreement utilizing single sided printing.

MEDICATION REVIEW: Medication review began at 01:39 PM. Medications are stored centrally and securely in a cabinet in the hallway. Medications for two (2) residents were observed. All medications observed were documented appropriately on their centrally stored medication and destruction record sheets and their Medication Administration Record sheets. No deficiencies were observed during medication review.

Continued on LIC 809C.
NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: COLONY OF THOUSAND OAKS AT SIDLEE, INC.
FACILITY NUMBER: 565850483
VISIT DATE: 07/14/2025
NARRATIVE
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly; the facility's last emergency disaster drill was conducted on 06/27/2025. The facility’s emergency disaster plan is up to date and is adequate. Both the infection control plan and the emergency disaster plan were reviewed/updated annually by the facility’s Administrator.

INTERVIEWS: LPA interviewed one (1) staff and one (1) resident. The resident interviewed stated that the staff treat them well and are attentive to their needs. The resident interviewed had no concerns with the facility. The staff member interviewed was knowledgeable on their role and responsibilities, resident rights, the different forms of abuse and the appropriate reporting procedures for suspected abuse.

During today’s visit LPA obtained a copy of the facility’s LIC 500, resident roster, and liability insurance.

Pursuant to Title 22 of the CA Code of Regulations, the following deficiencies and civil penalty were cited (refer to LIC 809-D): Exit interview conducted and copy of the report was issued and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Kasandra Lopez
NAME OF LICENSING PROGRAM ANALYST: Trevor Byrne
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 07/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/14/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2025 03:40 PM - It Cannot Be Edited


Created By: Trevor Byrne On 07/14/2025 at 03:10 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, INC.
FACILITY NUMBER: 565850483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87307(e)(2)(A)
Personal Accommodations and Services
(e) The licensee shall supervise residents as needed and as determined by the resident's appraisal pursuant to Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, when residents are in proximity to or when there is use of the following items: (2) Fishponds, wading pools, hot tubs, swimming pools, or similar larger bodies of water. (A) The licensee shall ensure that the bodies of water specified above are inaccessible through fencing, covering, or other means when not in active use by residents.

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 backyard pool lock was not properly secured making the body of water accessible to clients in care which poses an immediate safety risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
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Licensee secured the pool, replaced the lock with a keyed lock, and had a conversation with facility staff on the importance of ensuring the pool gates remain locked at the facility. POC cleared.
Type A
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

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 a disinfectant spray and the facility's cleaning supply closed was unlocked and unsecured at the time of the visit which posed an immediate safety risk to persons in care.
POC Due Date: 07/14/2025
Plan of Correction
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Licensee secured the chemical closet and disinfectant spray at the time of the visit. Additionally, the licensee had a conversation with facility staff educating them on the importance of securing chemicals at the facility. POC 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.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/14/2025 03:40 PM - It Cannot Be Edited


Created By: Trevor Byrne On 07/14/2025 at 03:10 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, INC.
FACILITY NUMBER: 565850483

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/14/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87507(a)(1)(A)
Admission Agreements
(a) The licensee shall complete an individual written admission agreement, as defined in Section 87101(a), with each resident or the resident's representative, if any. (1) The text of the admission agreement, including any attachments and modifications, shall be: (A) Printed in black type of not less than 12-point type size, on plain white paper. The print shall appear on one side of the paper only.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as one resident's admission agreement was printed utilizing both sides of the paper which poses a potential personal rights risk to persons in care.
POC Due Date: 07/28/2025
Plan of Correction
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Licensee agreed to reprint the admission agreement utilizing only one side of the paper and obtain updated signatures for the new form no later than POC due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kasandra Lopez
NAME OF LICENSING PROGRAM MANAGER:
Trevor Byrne
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 07/14/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/14/2025


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