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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850209
Report Date: 09/19/2023
Date Signed: 09/19/2023 12:46:06 PM


Document Has Been Signed on 09/19/2023 12:46 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. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:OAKMONT OF AGOURA HILLSFACILITY NUMBER:
195850209
ADMINISTRATOR:SAHAR MOSALLAFACILITY TYPE:
740
ADDRESS:29353 CANWOOD STREETTELEPHONE:
(747) 755-5700
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:102CENSUS: 79DATE:
09/19/2023
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
10:30 AM
MET WITH:Lily Chaparyan - Executive DirectorTIME COMPLETED:
01:00 PM
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Licensing Program Analyst (LPA) Brian Balisi conducted an unannounced Case Mangement - Incident visit to follow up on a LIC 624 Incident report and SOC 341 received by the department on 08/17/2023. LPA met with Executive Diretor Lily Chaparyan and explained the reason for the visit.

On 08/172023, the department reviewed a LIC624 for Resident #1 (R1) along with a SOC 341,both sent by facility staff. The reports indicated that on 08/13/2023, staff observed a bruise on R1's lower left arm and R1 stated that two (2) caregiver gave R1 the injury.

At approx 10:30am, LPA conducted physical plant, interviewed staff as well as reviewed and obtained pertinent documents relevant to the investigation. LPA did not observe any immediate or potential health and safety concerns at this time.

The LPA has determined further investigation is needed and will return at a later date to complete the investigation if warranted.

Exit interview conducted and copy of report issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 09/19/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/19/2023
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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