COLONY OF THOUSAND OAKS AT SIDLEE WEST INC

Official classification

Type A

Official code

87202(a)

Regulation authority

CCR

What the official deficiency says

(a) All facilities shall maintain a fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal. Prior to accepting or retaining any of the following types of persons, the applicant or licensee shall notify the licensing agency and obtain an appropriate fire clearance approved by the city, county, or city and county fire department or district providing fire protection services, or the State Fire Marshal: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review the licensee did not comply with the section cited above in 2 out of 4 staff rooms were not disclosed and did not obtain fire clearance which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/29/2025 Plan of Correction The Licensee will provide CCL an updated floor plan and obtain fire clearance by POC due date.

Official classification

Type A

Official code

87305(a)

Regulation authority

CCR

What the official deficiency says

(a) Prior to construction or alterations, all facilities shall obtain a building permit. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, interview, and record review, the licensee did not comply with the section cited above in the Licensee did not obtain permits for alterations which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/29/2025 Plan of Correction The Licensee will obtain building permits for the additional rooms and provide it to CCL by POC due date.

Official classification

Type A

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 2 out of 2 exit passageways were obstructed by furniture which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/28/2025 Plan of Correction The Licensee's maintenance man cleared the exits and passageways during the visit. POC Cleared.

Official classification

Type A

Official code

87355(e)(3)

Regulation authority

CCR

What the official deficiency says

(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (3) Request a transfer of a criminal record clearance as specified in Section 87355(c) or This requirement is not met as evidenced by: Deficient Practice Statement Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 6 staff were not associated with the facility which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 10/29/2025 Plan of Correction The Licensee will request criminal record transfers for all applicable staff and provide CCL proof by POC due date.

Official classification

Type B

Official code

87303(c)

Regulation authority

CCR

What the official deficiency says

(c) All window screens shall be clean and maintained in good repair. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above in 3 windows had screens in disrepair and 1 window did not have a screen which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 11/04/2025 Plan of Correction The Licensee will repair the window screens and send proof to CCL by POC due date.

Official classification

Type B

Official code

87465(h)(5)

Regulation authority

CCR

What the official deficiency says

87465(h)(5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers. This requirement is not met as evidenced by: Based on observation, the licensee did not comply with the section cited above in five (5) out of five (5) residents medications were pre-sorted which poses/posed a potential health, safety or personal rights risk to persons in care.

Official plan of correction

Administrator will provide a statement to CCL by the indicated date confirming their understanding of this regulation and their intent to abide by it. Administrator will speak to staff about the importance of not pre-sorting medications along with providing a signed statement with all staff.

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.