<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191202146
Report Date: 03/10/2022
Date Signed: 03/10/2022 02:26:04 PM


Document Has Been Signed on 03/10/2022 02:26 PM - It Cannot Be Edited

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:63CENSUS: 31DATE:
03/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Denise Gotto, Executive DirectorTIME COMPLETED:
02:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Rosaura Valenzuela and conducted an unannounced Required 1 year infection control inspection to the facility.

LPA met with the Executive Director The purpose of the visit was discussed.

At 10:17am, with the assistance of the ED, LPA conducted a tour of the facility inside and out.

There are two entrances being utilized at the facility, there are required posters posted at the main doors. Screening area is located immediately upon entrance. LPA was screened upon entry.

The facility had submitted and approved Mitigation Plan.

Signs to wear a mask and other COVID-19 prevention protocol signs were posted outside the door. Hand washing, coughing etiquette, physical distancing and other necessary signs were posted in the bathroom and all over the facility. The facility has a designated visitors' area in the patio. The facility has sufficient stock of PPE.

    See 809-C to continue
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:
DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 03/10/2022
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
VISIT DATE: 03/10/2022
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility consists of 2 main buildings. One building named The Lodge houses the activity room, dinning room, and kitchen services. The assisted living is located on the top floor and the memory care unit is located on the bottom floor of Oaks Hall.

The assisted living and memory care rooms have appropriate furniture. Common areas were observed to be neat and clean.

The facility maintains a comfortable temperature at 78 degrees. The smoke detectors are hardwired and interconnected and observed to be operational. There are carbon monoxide detectors in the facility. Fire extinguishers are located throughout the facility and were last serviced in August of 2021.

The bathrooms were checked for cleanliness and proper operation. LPA observed the appropriate grab bars in the showers and toilets. The hot water temperature was measured at 109.2 degrees F.

Medications-LPA observed medications to be in the nurses station and it was locked and inaccessible to residents. There is one (01) complete first aid kit.

Exit interview conducted. A copy of this report was issued and signature obtained.
No deficiencies were issued at this time
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: (818) 421-5360
LICENSING EVALUATOR SIGNATURE:

DATE: 03/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/10/2022
LIC809 (FAS) - (06/04)
Page: 2 of 2