Pre-licensing visit·September 28, 2021

Licensing Program Analyst (LPA) Martha Guzman Chavez conducted an announced Pre-licensing visit to the above facility on 9/28/2021 at 8:30am. LPA met with Licensee Representative Gilliana Sherman as this is a change of ownership application from Thousand Oaks Home Care II #561704150 to 9 West Sidlee LLC #565850195. Licensee Representative completed Comp II on 09-10-2021 and Comp III on 09-24-2021. Entrance interview conducted. The applicant has obtained fire clearance for a total capacity of 1 (one) bedridden and 5 (five) non-ambulatory, for a total capacity of six (6) clients. Facility currently has six (6) non-ambulatory residents. Facility has seven (7) bedrooms and three and a half (3 1/2) bathrooms. All six (6) resident bedrooms are single occupancy. Seventh bedroom is for staff. LPA observed a central entry point by the entrance designated for temperature checks and check-in for staff, residents, and visitors. The smoke detectors and carbon monoxide detector were tested and were operational. LPA observed one (1) fire extinguisher in the kitchen to be fully charged and last serviced on 03-17-2021. LPA observed first aid kit and manual to be complete. The common living and dining areas are clean and properly furnished with seating, a table, and television for resident use. Facility currently has a working landline telephone. LPA observed ten (10) exit doors to have functioning auditory alarms when opened. All bedrooms, bathrooms, kitchen, and common areas windows have clean window coverings with screens and in good repair. Appliances in the kitchen were clean and all appeared functional. Facility has two (2) refrigerators, one in the kitchen and one in the garage. Both are fully stocked. LPA observed a sufficient supply of non-perishable and perishable foods. Facility has emergency food and water for residents and staff. LPA observed a laundry room with a locked cabinet where detergent, harsh chemicals, and cleaning supplies are stored. Medication is stored in a locked cabinet adjacent to the kitchen. LPA observed one designated drawer next to the refrigerator where knives and sharps are locked and inaccessible to residents. LPA reviewed facility records at 9:25 am. Staff and resident files are in order and are kept locked in a cabinet adjacent to the kitchen. Hallways were free of any obstruction. (...Continued on LIC 809C...) (...Continued from LIC 809...) There are six (6) resident bedrooms that were properly furnished. LPA observed all bedrooms to have a bed with clean linens, a nightstand, and adequate lighting. There are three (3) bathrooms for resident use. Bathrooms were measured for hot water, first bathroom measured at 106 degrees Fahrenheit, second bathroom measured at 105.8 degrees Fahrenheit, and third bathroom measured at 105.2 degrees Fahrenheit. Each bathroom was adequately equipped with toilet paper and paper towels, as well as grab bars and non-skid mats. LPA observed a covered patio area with patio furniture, a table, and chairs for resident use. LPA observed one (1) fence gate that self-latches for resident use in case of an emergency. No large bodies of water accessible to residents . LPA observed CDSS PINs, Emergency Exit Plan and necessary posters posted in the hallway easily accessible to residents. No firearms or ammunition will be stored in the facility at any time. Facility is in compliance with Title 22 Regulations at this time. The CAB Analyst will notify the applicant when the license has been approved. Exit interview conducted. A hard copy was provided via email.