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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191202146
Report Date: 02/05/2021
Date Signed: 02/05/2021 05:24:57 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME:TWELVE OAKSFACILITY NUMBER:
191202146
ADMINISTRATOR:DENISE M GOTTOFACILITY TYPE:
740
ADDRESS:2820 SYCAMORE AVETELEPHONE:
(818) 862-0811
CITY:LA CRESCENTASTATE: CAZIP CODE:
91214
CAPACITY:63; 63CENSUS: DATE:
02/05/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Denise GottoTIME COMPLETED:
12:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Pitz conducted an unannounced case management visit on this day in order to follow up on technical assistance visit that was conducted along with Los Angeles County Department of Public Health on 2/2/21.

During the 2/2/21 visit, LPA was informed that there have been several COVID positive cases at the facility in the month of January that were not reported to Community Care Licensing (CCL). LPA spoke with administrator Denise Gotto today and obtained the full list of 15 resident cases that occurred in January but not reported to CCL. LPA reminded administrator of the importance of reporting all new staff and resident COVID cases to CCL as soon as possible.

Report reviewed, signed and delivered. Exit interview conducted, deficiency cited.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:

DATE: 02/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME: TWELVE OAKS
FACILITY NUMBER: 191202146
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/05/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/12/2021
Section Cited

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(B) Any serious injury as determined by the attending physician and occurring while the resident is under facility supervision.


This requirement is not met as evidenced by:
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Based on information provided by administrator the facility did not report 15 covid cases in January to CCL which poses an immediate risk to residents in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Cassandra HarrisTELEPHONE: (818) 596-4342
LICENSING EVALUATOR NAME: Alexander PitzTELEPHONE: (805) 450-1627
LICENSING EVALUATOR SIGNATURE:
DATE: 02/05/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/05/2021
LIC809 (FAS) - (06/04)
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