Pre-licensing visit·April 11, 2025

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 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.