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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850344
Report Date: 04/09/2024
Date Signed: 04/10/2024 09:08:14 AM


Document Has Been Signed on 04/10/2024 09:08 AM - 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:
195850344
ADMINISTRATOR:CHAPARYAN,LILITFACILITY TYPE:
740
ADDRESS:29353 CANWOOD STREETTELEPHONE:
(747) 755-5700
CITY:AGOURA HILLSSTATE: CAZIP CODE:
91301
CAPACITY:102CENSUS: 78DATE:
04/09/2024
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Lilit Chaparyan - Executive DirectorTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA)s Brian Balisi and Valeria Conway conducted a pre-licensing visit to this property at 09:45AM.  LPA's with Lilly Chaparyan and explained the reason for the visit.  This application is for a Change of Ownership Application (CHOW) currently operating with Facility license # 195850209 and the current licensed facility has residents in care. The applicant has obtained fire clearance for Ninety Four  (94) non-ambulatory and eight (8) bedridden with a total capacity of One hundred and two  (102) residents. Chaparyan stated there is a pending hospice care waiver.

The facility is a 2 story residence and consist of a total of eighty (80) apartments. At approx. 10:00am, a physical tour was conducted inside and out. There are fire sprinklers and fire doors throughout the facility.

The kitchen was observed to be inaccessible to residents in care. Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Dining room furniture were observed to be in good condition and appeared to be relatively clean.  The supply of dishes, utensils, pots, pans and drinkware is adequate. The freezer was maintained at zero degrees Fahrenheit (0*F) and the refrigerator was maintained at 40*F.  There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional at the time of the visit. Trash cans had tight fitting lids. No flies or other vermin were observed.

LPA's inspected randomly selected rooms in both memory care and Assisted living. All  resident rooms are set up with beds, nightstands, lamps, chests of drawers, chairs and closet space. The beds are furnished with box springs, comfortable mattress and clean linen; which includes, a mattress pad, top and bottom linens, pillowcases, blanket (if needed) and a bedspread.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:
DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 04/09/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OAKMONT OF AGOURA HILLS
FACILITY NUMBER: 195850344
VISIT DATE: 04/09/2024
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Continued from 809
Lighting in the rooms appeared adequate.  In addition, no bedroom was used as a passageway to another room, bath or toilet. There is no staff room at the facility. For NOC , there will be awake night staff only. All rooms were free of odors. All window screens were clean and maintained in good repair. The resident bathroom(s) have a shower with non-skid materials.  The toilet and shower have grab bars. The hot water temperature was tested in the bathrooms and the kitchen and was found to be within the range of 105*F and 120*F.

LPAs inspected the common areas throughout the facility including the Activity room, Lobby, reading room, lounge, café, fitness center, and movie theatre. The common areas include the following on the All the rooms have been appropriately furnished. There is a dedicated area for the posting of required documents directly by the main entrance and hallway. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. All exits in Memory care have functioning auditory devices and were operational at the time of the visit. The LPAs observed required postings throughout the common spaces. Resident and staff records were stored inaccessible in med room and office areas. Medications were observed centrally stored in a med room on the 2nd floor of assisted living and in the Med room on the first floor in memory care. Both rooms were observed to be inaccessible to residents in care.

Resident records review began at 11:55 am, six  (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms.  Staff records review began at 1pm,  Six (6) personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Daily vehicle inspection list and California Highway Patrol Inspection report was reviewed for facility vehicles. All records were observed to be in order at this time. The first aid supplies were complete , including a thermometer and a current version of a first aid manual. First aid was observed stored inaccessible in the medication cabinet as well.

Medications review began at approximately 01:45pm, The medications are centrally stored in a med room on the 2nd floor inaccessible to residents in care. Medications are properly documented on the centrally stored medications and destruction record.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OAKMONT OF AGOURA HILLS
FACILITY NUMBER: 195850344
VISIT DATE: 04/09/2024
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Continued from 809-C

Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of a communicable disease The facility’s policies and procedures as it pertains to infection control are adequate.

Component III was conducted in conjunction with the visit.

During the visit Executive Director Lilit Chaparyan had to leave the facility for a previous appointment, but stated Beatriz Martinez, Health Services Director will sign in their place.
 
No corrections required  on a pre-licensing visit at this time. Exit interview conducted. Report issued and provided to Licensee representative.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian BalisiTELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:

DATE: 04/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/09/2024
LIC809 (FAS) - (06/04)
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