565850559-3-11-2025-29-AS-KDUK-DENVV8-20250311164555

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850559
Report Date: 03/11/2025
Date Signed: 03/11/2025 04:46:28 PM

Document Has Been Signed on 03/11/2025 04:46 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, THE		FACILITY NUMBER:	565850559
ADMINISTRATOR/ DIRECTOR:	BUCK-PLASSMEYER,JOAN		FACILITY TYPE:	740
ADDRESS:	24 W SIDLEE STREET		TELEPHONE:	(805) 258-2931
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 4	DATE:	03/11/2025
TYPE OF VISIT:	Post Licensing	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Molly Buck		TIME VISIT/ INSPECTION COMPLETED:	04:55 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek conducted an unannounced post-licensing visit to this facility at 11:00AM. LPA met with co-Administrator Molly Buck. Entrance interview conducted.

Beginning at 11:28AM, the LPA, along with co-Administrator 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:

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 6 (six) total bedrooms, all of which are designated for private resident use.

RESTROOMS: The LPA observed 4 (four) restrooms in the facility; 2 (two) are shared restrooms and 2 (two) are designated for private resident use. Resident restrooms were observed to be clean and sanitary and in operating condition with grab bars and slip resistant surfaces. Water temperature was measured in the common restroom and measured at 116.2 degrees Fahrenheit.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Knives and other sharps were observed locked in a kitchen drawer. Cleaning supplies were observed in a locked under-sink cabinet. Fire extinguisher was observed to be fully charged and purchased 09/23/2024.

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 is not 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 has a pool, which was properly fenced and locked.

Report Continued on LIC 809-C

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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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Document Has Been Signed on 03/11/2025 04:46 PM - It Cannot Be Edited

Created By: Kelly Dulek On 03/11/2025 at 04:02 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: LEGACY COLLECTION AT SIDLEE, THE	FACILITY NUMBER: 565850559
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/11/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87355(e)(3)

Criminal Record Clearance

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above as 1 (one) staff was observed to be employed with the facility since February 2025 but does not have criminal record clearance transfered to this location, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 03/11/2025
	Plan of Correction
1 2 3 4	Facility representative filled out the LIC 9182 form during today's visit and LPA transfered the staff's fingerprint clearance to this location during the visit. POC cleared.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: 03/11/2025

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: LEGACY COLLECTION AT SIDLEE, THE	FACILITY NUMBER: 565850559
	VISIT DATE: 03/11/2025

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RECORD REVIEW: Began at 12:15PM, 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, and personal rights. 4 (four) resident records reviewed were complete and contained all required documents. 5 (five) staff files were reviewed; 1 (one) staff file reviewed did not contain proof of fingerprint background clearance transfer prior to employment. All other staff files reviewed were observed to be in compliance.

MEDICATION REVIEW: Began at 03:00PM. Medications for 2 (two) residents were observed. No discrepancies were observed during medication review.

INFECTION CONTROL/EMERGENCY DISASTER PLAN: During today’s visit, the LPA reviewed the facility’s infection control practices. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete. Emergency disaster drills will be conducted quarterly.

INTERVIEWS: Throughout today's visit, LPA interviewed both residents and staff. No concerns were noted.

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

Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:	DATE: 03/11/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/11/2025

LIC809 (FAS) - (06/04)

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