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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606758
Report Date: 08/07/2024
Date Signed: 08/07/2024 03:53:05 PM


Document Has Been Signed on 08/07/2024 03:53 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:CHATEAU OF OAKSFACILITY NUMBER:
197606758
ADMINISTRATOR:ROLANDO & LILY LAZATINFACILITY TYPE:
740
ADDRESS:15239 CAMARILLO STREETTELEPHONE:
(818) 510-0080
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY:6CENSUS: 5DATE:
08/07/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Rolando LazatinTIME COMPLETED:
04:05 PM
NARRATIVE
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Licensing Program Analysts (LPA) Sandra Urena and Erica Mosley arrived at the facility unannounced to conduct a required annual inspection at 10:00 a.m. LPAs were greeted by staff. The Administrator Rolando Lazatin arrived shortly thereafter, and the LPAs explained the reason for the visit.

At 10:20 a.m., LPAs, staff and the administrator conducted a tour inside, and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff. Toxic materials are locked, and out of reach of residents. Upon inspection, at 10:28 a.m., LPAs noticed a box with medications sitting in an area between the living room and kitchen area, and accessible to residents in care. Additionally, LPAs observed three small lighters in a kitchen drawer accessible to residents in care. Water temperature was withing regulation limits.

BEDROOMS: Five bedrooms were observed to be furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition. Extra linens were observed in the hallway cabinet.

COMMON AREAS: The common seating area, and dining room furniture was observed to be clean and in good condition. Fire extinguisher was observed to be purchased on 07/23/2024. The walls and flooring were observed to be clean and in good condition.

Continues on LIC 809C…

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
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 6


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: CHATEAU OF OAKS
FACILITY NUMBER: 197606758
VISIT DATE: 08/07/2024
NARRATIVE
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BATHROOM: Bathrooms were observed to be clean; shower area was in clean condition with grab bars, and a non-skid mat available. Hand washing signs were displayed, and enough soap, and paper products in each restroom. Water temperature was withing regulation limits.

OUTDOOR: Backyard has a patio area and has patio shade umbrella and patio furniture for residents’ use. No open bodies of water were noted.



RECORDS: Records review began at 11:22 a.m. Residents’ records were reviewed for, but not limited to care plans, medical records, admissions agreement, and consent forms. Two out of three residents’ records were missing an updated appraisal assessment. Two residents’ files were not available for review, licensee stated that the files were damaged by water and licensee was in the process of creating new files. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate annual training. Four out of four files were missing the annual mandated 20-hour training.

MEDICATIONS: Medications review began at 1:06 p.m.; medications are centrally stored and locked in a cabinet in the kitchen area; medications are labeled and checked for expiration dates. Medications are properly documented in the centrally stored medications and destruction record. No errors were observed during the medication review.

INFECTION CONTROL: 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 COVID-19.

The LPA obtained the following documents:


- LIC500 Personnel Report

Deficiencies were cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISOR'S NAME: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:

DATE: 08/07/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 2 of 6
Document Has Been Signed on 08/07/2024 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CHATEAU OF OAKS
FACILITY NUMBER: 197606758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(1)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in six out of six medications containers which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 08/14/2024
Plan of Correction
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Licensee agreed to provide training to staff and will submit proof of correction to LPA vai email by POC Due Date
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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4
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 08/07/2024 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CHATEAU OF OAKS
FACILITY NUMBER: 197606758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87208(a)
Plan of Operation
(a) Each facility shall have and maintain a current, written definitive plan of operation. The plan and related materials shall be on file in the facility and shall be submitted to the licensing agency with the license application. Any significant changes in the plan of operation which would affect the services to residents shall be submitted to the licensing agency for approval. The plan and related materials shall contain the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation,and interview, record review, the licensee did not comply with the section cited above in one out of one floor plans did not match the map on record at CCL, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/08/2024
Plan of Correction
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Licensee has agreed to contact the LAFD to schedule an insoection visit and will submit a date to LPA via email.
Type B
Section Cited
HSC
1569.696(a)
Other Provisions
(a) All residential care facilities for the elderly shall provide training to direct care staff on postural supports, restricted conditions or health services, and hospice care as a component of the training requirements specified in Section 1569.625. The training shall include all of the following:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of three staff didnot receive the annual 20 hour training which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/31/2024
Plan of Correction
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Licensee agreed to provide training to staff and submit proof of training to LPA by the POC due Date.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 4 of 6


Document Has Been Signed on 08/07/2024 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CHATEAU OF OAKS
FACILITY NUMBER: 197606758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(c)
Other Provisions
(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above as in two out of four quartely drills were not conducted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Licensee agreed to conduct a a quartely drill by POC Due Date and send proof to LPA via email.
Type B
Section Cited
HSC
1569.695(d)
Other Provisions
(d) A facility shall review the plan annually and make updates as necessary, including changes in floor plans and the population served. The licensee or administrator shall sign and date documentation to indicate that the plan has been reviewed and updated as necessary.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of one floor plans wer not updated and posted which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Licensee agrre to update the floor plan with emergency exits/meeting place and will submit to LPA by POC Due Date.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 08/07/2024 03:53 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: CHATEAU OF OAKS
FACILITY NUMBER: 197606758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 08/07/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(1)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (1) A resident roster with the date of birth for each resident.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in one out of total Resident Roster (LIC 9020) was not available at time of inspection. which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/09/2024
Plan of Correction
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Licensee agreed to submit correction to LPA by POC Due Date.
Type B
Section Cited
CCR
87611(d)
General Requirements for Allowable Health Conditions
(d) In addition to Section 87463, Reappraisals and Section 8, Observation of the Resident, the licensee shall monitor the ability of the resident to provide self care for the allowable health condition and document any change in that ability.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in two out of three reappresials were not completely filled out and signed by responsible partys and administrator, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 08/23/2024
Plan of Correction
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Licensee agreed to submit proof of corrections to LPA by POC Due Date.
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: Kasandra LopezTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Sandra UrenaTELEPHONE: 747-230-3919
LICENSING EVALUATOR SIGNATURE:
DATE: 08/07/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/07/2024
LIC809 (FAS) - (06/04)
Page: 6 of 6