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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850594
Report Date: 04/11/2025
Date Signed: 04/11/2025 02:51:26 PM

Document Has Been Signed on 04/11/2025 02:51 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 MARIAN, THEFACILITY NUMBER:
565850594
ADMINISTRATOR/
DIRECTOR:		BUCK-PLASSMEYER, JOANFACILITY TYPE:
740
ADDRESS:1730 N MARIAN AVETELEPHONE:
(805) 258-2931
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 0DATE:
04/11/2025
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:10 AM
MET WITH:Joan Buck-Plassmeyer & Molly BuckTIME VISIT/
INSPECTION COMPLETED:
01:32 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 and Molly Buck. Entrance interview conducted.

The facility obtained a fire clearance on 01/30/2025 for 5 (five) non-ambulatory and 1 (one) bedridden (in bedroom #1, 3 or 5), with a total capacity of 6 (six) residents. The Licensee Representatives submitted a hospice waiver request for 2 (two) residents, which is pending at this time. The facility also has a dementia care plan pending. Component II was completed telephonically with the assigned CAB Analyst. Component III was completed on 10/10/2024 with the Applicant Representatives.

The facility is a single-story home in the Thousand Oaks area, which consists of 6 (six) bedrooms and 7(seven) bathrooms. There is no staff room and Applicant stated that staff will remain awake at night. Beginning at 11:47AM, 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:

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-slip surfaces. There are 4 (four) private en-suite restrooms designated for resident use. There are an additional 3 (three) half-baths, 2 (two) of which are designated for resident use and 1 (one) is for staff and guest use. The facility also contains a separate shower room for resident use. Hot water was measured in a sample of resident restrooms 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
NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/11/2025
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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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.

LIC809 (FAS) - (09/23)
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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 MARIAN, THE
FACILITY NUMBER: 565850594
VISIT DATE: 04/11/2025
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COMMON AREAS: The 2 (two) living rooms and dining area 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. Representatives stated they plan to install auditory devices on all exits, should any potential residents present a risk of exiting. Common areas maintained a comfortable temperature during the visit. Hardwired combination smoke alarms and carbon monoxide detectors and fire doors were tested at 12:43PM and were operational at the time of the visit. Fire extinguishers were observed to be fully charged and purchased on 12/31/2024. First aid supplies were reviewed and observed to be in compliance.

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.

GARAGE: LPA observed the locked attached garage to contain laundry area, staff/office area, emergency food and water supply, and storage. Medications will be stored and prepared in a locked cabinet inside the garage.

OUTDOOR SPACE: The back yard area is enclosed. The exit gate was 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. The backyard does have a pool, which was properly enclosed and locked. All passageways were observed to be free of obstructions.

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.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Kelly Dulek
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 04/11/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/11/2025
LIC809 (FAS) - (06/04)
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