197610531-4-3-2024-31-AS-RCOR-D3YLPN-20240403085611

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197610531
Report Date: 03/22/2024
Date Signed: 04/03/2024 08:56:37 AM

Document Has Been Signed on 04/03/2024 08:56 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
WOODLAND HILLS S.RO, 21731 VENTURA BLVD., STE. 250
WOODLAND HILLS, CA 91364

FACILITY NAME:	A SIWA OASIS		FACILITY NUMBER:	197610531
ADMINISTRATOR:	SZALONEK, FE		FACILITY TYPE:	740
ADDRESS:	15112 ROXFORD STREET		TELEPHONE:	(747) 246-3242
CITY:	SYLMAR	STATE: CA	ZIP CODE:	91342
CAPACITY:	6	CENSUS: 0	DATE:	03/22/2024
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:36 AM
MET WITH:	Akhilesh Jha		TIME COMPLETED:	12:35 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 (LPAs) Ray Comer and Gary Tan conducted an announced Pre-Licensing visit to this facility and met with Licensee representative Akhilesh Jha. The applicant is "Oasis Manors Inc.,". Fire Clearance dated 01/24/24 was received for six (6) non-ambulatory residents, all (6) of which maybe bedridden. Purpose of today’s visit is to inspect the facility to ensure that the facility is in compliance with the rules and regulations of California Code of Regulations, Title 22, Division 6. Facility is a single-story home. Today's site visit consisted of LPAs touring the physical plant at 9:50 AM inside and outside and observed the following: The facility smoke alarm system is hard wired and interconnected. Fire extinguishers are located on wall of near the dining area and another fire extinguisher located in the common living area; both extinguishers are observed to be fully charged and purchased on 11/02/23. The facility maintains dual Carbon Monoxide/Smoke alarm detectors installed throughout the common areas of the facility. Alarms were tested and observed to be operational. The facility is equipped with sprinkler system. There is a functioning telephone on the premises. An emergency exit plan/sketch is posted on the hallway wall with other posting requirements. There are five (5) resident bedrooms which are private with one bathroom for each room, and one (1) shared bedroom. Resident bedrooms were observed to be appropriately furnished. The common areas (living room, kitchen and dining areas) were appropriately furnished, and lighting was adequate. The living room is furnished with comfortable furniture. Residents and staff records will be stored in a secured filing cabinet in the office in another building within the compound. Medications will be stored in the cabinet along the bedroom hallway observed with a locking mechanism. The first aid kit is readily available in the drawer in the screening area. The bathrooms have appropriate grab bars installed and non-skid mats. Hot water was tested in residents’ bathrooms and measured at 107.2°F.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

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: A SIWA OASIS	FACILITY NUMBER: 197610531
	VISIT DATE: 03/22/2024

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(Continued from LIC 809)

The kitchen knives and sharps will be stored in a locked drawer in the kitchen. Kitchen cleaning supplies are stored in a locked in the cabinet below the sink. Laundry detergents, cleaning supplies and other toxins are stored in a locked cabinet in the laundry area. The laundry area is in a closeted space in the hallway area of the facility. Facility maintains the necessary precautions to safely house dementia residents such as auditory alarms on all doors and locked areas for centrally stored medications. Auditory alarms were tested and observed to be operational. Facility appears to be clean and in good repair. Appliances in the kitchen appeared to be functional.

A visitor sign-in sheet and screening station were present at the facility entrance. Sign in sheet, hand sanitizer, gloves and masks were observed. Required poster are posted all over the facility. The facility has submitted a Mitigation and Infection plan.

There is a sitting area in the front, side and backyards for residents to conduct outdoor activities. The backyard is fenced. The backyard area has a swimming pool which is appropriately fenced and observed to be locked. There is a Infra-red Sauna beside the swimming pool. There is a storage area near the front gate for PPE and other supplies. The front of the facility maintains an open car port parking space. Facility does not have a garage.

Component III was conducted with the licensee representative and his house manager, Aurora Solis.

Facility is in compliance with Title 22 Regulations at this time. This report will be forwarded to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved.

Exit interview conducted and copy of this report issued.

SUPERVISOR'S NAME: Eva Miller	TELEPHONE: (818) -596-4373
LICENSING EVALUATOR NAME: Raymond Comer	TELEPHONE: 818-401-8655
LICENSING EVALUATOR SIGNATURE:	DATE: 03/22/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/22/2024

LIC809 (FAS) - (06/04)

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