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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850559
Report Date: 10/10/2024
Date Signed: 10/10/2024 02:49:19 PM

Document Has Been Signed on 10/10/2024 02:49 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:LEGACY COLLECTION AT SIDLEE, THEFACILITY NUMBER:
565850559
ADMINISTRATOR/
DIRECTOR:		BUCK-PLASSMEYER,JOANFACILITY TYPE:
740
ADDRESS:24 W SIDLEE STREETTELEPHONE:
(805) 258-2931
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 0DATE:
10/10/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Joan Buck-Plassmeyer & Molly BuckTIME VISIT/
INSPECTION COMPLETED:
02:55 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 Joan Buck-Plassmeyer, Molly Buck, and Craig Plassmeyer. Entrance interview conducted.

The facility obtained a fire clearance on 08/28/2024 for 5 (five) non-ambulatory and 1 (one) bedridden (in bedroom #1), with a total capacity of 6 (six) residents. The Licensee Representatives submitted a hospice waiver request for 6 (six) residents, which is pending at this time. The facility also has a dementia care plan pending. Component II was completed on 09/23/2024. 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 6 (six) bedrooms and 4 (four) bathrooms. There is no staff room and Applicant stated that staff will remain awake at night. Beginning at 10:12AM, 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:

KITCHEN/FOOD SERVICE AREA: The facility has a sufficient supply of non-perishable foods, emergency food and water. Knives and sharp items will be stored in a locked drawer in the kitchen island. 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 kitchen cabinet. Files will be stored in a separate locked kitchen cabinet.

RESIDENT BEDROOMS/BATHROOMS: The resident bedrooms were observed. All 6 (six) bedrooms are fully furnished for resident use. The resident bathrooms were observed to be clean and sanitary with non-skid tiles, strips and available mats. 2 (two) bathrooms did not have grab bars by the toilets. Hot water was measured in a common resident restroom and measured within the required range. The facility has a sufficient supply of linens and towels. Facility has a call button system for resident use.


Report continued on LIC 809-C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/10/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: LEGACY COLLECTION AT SIDLEE, THE
FACILITY NUMBER: 565850559
VISIT DATE: 10/10/2024
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COMMON AREAS: The living room and 2 (two) dining areas are furnished appropriately. A fireplace was observed in the living room to be inaccessible to residents. Paint, windows, window coverings, and floors are in good repair. The LPA observed the required postings in the common areas. Auditory devices on all exits were operational. Common areas were maintained at 71 degrees during the visit. Hardwired combination smoke alarms and carbon monoxide detectors and fire doors were tested at 12:12PM and were operational at the time of the visit. Fire extinguisher was observed to be fully charged and Applicant stated it was recently purchased. LPA advised Applicant to maintain the receipt from purchase or proof of annual inspection. First aid supplies were reviewed and observed to be in compliance. LPA observed the locked garage to contain laundry area, staff/office area, extra cleaning supplies, and storage.

OUTDOOR SPACE: The back yard area is enclosed. One gate was observed to be self-closing and self-latching. The other gate was locked and will not be used as a passageway or resident exit. The backyard contains a shaded seating area and appropriate outdoor furnishings, as well as outdoor activity supplies. The backyard does have a pool, which was properly enclosed and locked.

The following needs to be corrected/proof provided to Community Care Licensing (CCL) prior to Licensure:

  • Grab bars need to be installed in 2 restrooms - by the toilet in restroom #1 and by the toilet in restroom #4.

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: 10/10/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/10/2024
LIC809 (FAS) - (06/04)
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