Facility Evaluation Report

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.