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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850536
Report Date: 11/19/2024
Date Signed: 11/19/2024 01:44:49 PM

Document Has Been Signed on 11/19/2024 01:44 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:ARRAY ASSISTED LIVINGFACILITY NUMBER:
565850536
ADMINISTRATOR/
DIRECTOR:		FERMO, BRANDON JOSHUAFACILITY TYPE:
740
ADDRESS:212 WEST GAINSBOROUGH ROADTELEPHONE:
(805) 795-2494
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 0DATE:
11/19/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:18 AM
MET WITH:Brandon Fermo, Maria Fermo, Joselyn ZanoTIME VISIT/
INSPECTION COMPLETED:
01:50 PM
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Licensing Program Analyst (LPA) Kelly Dulek conducted an announced Pre-Licensing inspection at the facility today and met with Licensee Representatives/Applicants Brandon Fermo, Maria Fermo and Joselyn Zano. Entrance interview conducted.

The facility obtained a fire clearance on 05/31/2024 for 5 (five) non-ambulatory and 1 (one) bedridden, with a total capacity of 6 (six) residents. The Licensee Representatives submitted a hospice waiver request for 2 (two) hospice residents and included a dementia care plan in the application. Component II was completed on 10/29/2024. During today's visit, LPA completed Component III with the Applicant Representatives.

The facility is a single-story home in the Thousand Oaks area, which consists of 5 (five) bedrooms and 3 (three) bathrooms. There is no staff room and Applicant stated that staff will remain awake at night. Beginning at 10:29AM, the LPA, along with Applicant Representatives, conducted a physical plant tour to ensure there are no health and safety hazards and the facility is in compliance with regulation. The following was observed:

COMMON AREAS: The living room and dining area are furnished appropriately. Paint, windows, window coverings, and floors are in good repair. The LPA observed the required postings in the entry way and common areas. Auditory devices on all exits were operational. Common areas were maintained at 72 degrees during the visit. Combination hardwired smoke alarms and carbon monoxide detectors were tested at 01:18PM and were operational at this time. Fire extinguisher was observed to be fully charged and purchased on 03/30/2024. The facility has a separate laundry room located in the garage area, which contains an operational washing machine and dryer. LPA observed the garage to contain extra dry food storage, separate locked cleaning supplies, PPE supplies and storage. Activity supplies were observed, including games and puzzles. LPA observed a Ring doorbell/camera on the front entry. Licensee Representative disabled audio on the Ring camera. There is an office area adjacent to the living room and kitchen. The office area contains locked storage for resident and staff files.

Report continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/19/2024
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: ARRAY ASSISTED LIVING
FACILITY NUMBER: 565850536
VISIT DATE: 11/19/2024
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KITCHEN/FOOD SERVICE AREA: The facility has a sufficient supply of perishable and non-perishable foods, emergency food and water. Knives and sharp items will be stored in a locked drawer. Cleaning supplies and disinfectants will be stored underneath the locked kitchen sink and in the locked garage. The facility has a sufficient supply of plates, cups and utensils. Medications will be locked and centrally stored in a cabinet in the kitchen. First aid supplies were reviewed and observed to be in compliance.

RESIDENT BEDROOMS/BATHROOMS: All 5 (five) bedrooms are designated for resident use; 1 (one) is designated for shared resident use and the remaining 4 (four) are private resident rooms. All bedrooms are fully furnished for resident use. The resident bathrooms were observed to be clean and sanitary with grab bars and non-skid mats. Hot water was measured in resident restrooms and measured within the required range. The facility has a sufficient supply of linens and towels.

OUTDOOR SPACE: The back yard area is enclosed. Both gates were observed to be self-closing and self-latching. The backyard contains a shaded seating area and appropriate outdoor furnishings, as well as outdoor activity supplies. Backyard contains a storage shed, which was observed to be locked. There are no bodies of water on the premises.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview conducted. A copy of the report was provided.

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

DATE: 11/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/19/2024
LIC809 (FAS) - (06/04)
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