Pre-licensing visit·October 16, 2023

Licensing Program Analyst (LPA) Elsie Campos arrived at the facility announced at 10:30 a.m. to conduct a pre-licensing inspection and conducted a subsequent visit unrelated to the pre-licensing inspection at this facility. LPA met with Administrator Connie Roush. This is a change of ownership application from Colony of Thousand Oaks at Sidlee West, Inc. (#565850181) to Colony of Thousand Oaks at Sidlee West Inc. (#565850370). The current census is six for (6) residents, the facility currently has five (5) residents. The fire clearance was granted on 07/21/2023; in which all rooms were cleared for bedridden residents. Component III was waived as the applicant currently operates three other Residential Care Facilities for the Elderly (RCFE)’s that are currently in good standing. Applicant has attended Component III in the past and is RCFE administrator certified. The LPA toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. BEDROOMS : There are (8) eight bedrooms in the facility; the facility has (6) six private bedrooms for resident use, and (2) two staff rooms. Both staff rooms are kept locked. Room #4, #6 do not have direct access to the outside. Lighting in the rooms appeared adequate. (6) six out of (6) six private resident rooms and (2) staff rooms were set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. BATHROOMS : There is (1) half bath and (1) full bathroom in the hallway. There are two (2) private bedroom bathrooms for resident use; the half bathroom in the hallway is designated for staff and guests, the full bathroom in the hallway is designated for resident use. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between 105.0 – 108.6 degrees Fahrenheit. Continued on LIC 809-C. COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. The facility smoke alarm system is hardwired; the smoke detectors were operable at the time of the visit. There are two (2) fire extinguishers which were fully charged and last serviced 11/8/2022. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted at the entrance area wall. Other required postings are also posted on the dining area wall and living room wall. KITCHEN : Kitchen knives are stored locked and inaccessible in a drawer on the left hand side of the stove. The supply of perishable and nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and appeared functional. There is an adequate supply of emergency food. MEDICATIONS : Medications are in a locked closet in the main hallway. The first aid supplies were complete, including a first aid manual. FILES: Resident and staff records are stored in the medication closet. LAUNDRY : The laundry area is located in the hallway to the right of the facility next to bedroom #1. Laundry detergent and chemicals are locked and stored inaccessible in the laundry room. EXTERIOR : The exterior passageways were clean and clear of any obstructions. There is a covered patio area in the backyard with tables and chairs for resident use. There is a gated pool that was observed to be locked and inaccessible. The back and sides of the house are separated from the front yard by gates at the north and south-side passageways, both gates have self-latching mechanisms. There is no front yard gate or driveway gate.There are no other structures on the property. INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. Facility is in compliance with Title 22 Regulations at this time. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued.