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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 191202146
Report Date: 06/19/2024
Date Signed: 06/19/2024 04:12:18 PM


Document Has Been Signed on 06/19/2024 04:12 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
WOODLAND HILLS S.RO, 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:
(747) 255-7272
CITY:LA CRESCENTASTATE: CAZIP CODE:
91214
CAPACITY:63CENSUS: 35DATE:
06/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:10 AM
MET WITH:Denise Gotto, AdministratorTIME COMPLETED:
04:15 PM
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Licensing Program Analyst (LPA) Rosaura Valenzuela conducted an unannounced annual required inspection to the facility. LPA met with Executive Director Denise Gotto and explained the reason for the visit.

With the assistance of the ED, LPA conducted a tour of the facility both inside and outside.

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 2023.

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 118 degrees F.

Continue on 809-C
SUPERVISOR'S NAME: Naira MargaryanTELEPHONE: (818) 596-4368
LICENSING EVALUATOR NAME: Rosaura ValenzuelaTELEPHONE: 818-596-4334
LICENSING EVALUATOR SIGNATURE:
DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364
FACILITY NAME: TWELVE OAKS
FACILITY NUMBER: 191202146
VISIT DATE: 06/19/2024
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Medications-LPA observed medications to be in the nurses station and it was locked and inaccessible to residents in care. There is one (01) complete first aid kit.

No health and safety issues noted at the time of this visit.

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: 818-596-4334
LICENSING EVALUATOR SIGNATURE:

DATE: 06/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/19/2024
LIC809 (FAS) - (06/04)
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