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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850039
Report Date: 11/16/2023
Date Signed: 11/16/2023 03:45:50 PM


Document Has Been Signed on 11/16/2023 03:45 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:OAK PARK MANORFACILITY NUMBER:
405850039
ADMINISTRATOR:MEFFERT, ASTRIDFACILITY TYPE:
740
ADDRESS:1073 OLD OAK PARK ROADTELEPHONE:
(805) 540-1503
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY:32CENSUS: 18DATE:
11/16/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Astrid Meffert, AdministratorTIME COMPLETED:
03:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) De Leon conducted a case management deficiency visit to the facility above. LPA met with Astrid Administrator and explained the purpose of the visit.

LPA De Leon received a phone call on 11/02/2023 from the facility self-reporting that Resident 1 (R1) was able to AWOL from the facility and that R1 has been found with no injury and has been returned to the facility. Based on the incident report the facility had visitors and vendors coming in and out of the facility that morning and at some point R1 was able to get out the alarmed gate without being seen. At 9:30am R1 was observed by staff in the living room and at 10:00am R1 was walking in the courtyard. At 11:00am the facility got a call from a neighbor about a ¼ mile up the street that they had found R1 and wanted to know if R1 lived at the facility. The neighbor confirmed the name of R1 and told the facility they had called 911, the ambulance arrived and would transport R1 back to the facility. R1 arrived back at the facility without any injuries. The facility reported to all required parties.

The facility immediately put the following safety measures in place for R1:
R1's has a project live saver device for tracking and safety, facility implemented 30 minute checks on R1, when the facility has visitors or vendors coming in and out the staff will closely monitor R1 while alarms are off and doors are open, R1 agreed to move to a closer bedroom near the common areas of the facility, R1’s physician was contacted for discussion for managing R1’s wondering behaviors, a ring door bell cam was installed at the gate area where R1 was able to exit, a floor alarm was placed with permission in R1’s room so staff are notified when R1 is leaving R1’s room and staff are being trained on the new protocols for R1.

Exit interview conducted, deficiency cited, copy of report and appeal rights printed for Administrator.
SUPERVISOR'S NAME: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
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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Document Has Been Signed on 11/16/2023 03:45 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: OAK PARK MANOR
FACILITY NUMBER: 405850039

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/16/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/16/2023
Section Cited
CCR
87464(f)(1)

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(f) Basic services shall at a minimum include:(1) Care and supervision as defined in Section 87101(c)(3) and Health and Safety Code section 1569.2(c). This requirement was not met as evidenced by:
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The administrator agreed to hold an all-staff training for supervision of residents, duties, responsibilities, elopement procedures, and on audible alarm sounds and responses. Provide proof of training with all staff signatures and an up-to-date LIC 500 to CCL.
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Based on record review the licensee did not comply with the regulation above R1 was able to AWOL from the facility without anyone’s knowledge which poses an immediate health and safety risk to resident in care.
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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: Kelly BurleyTELEPHONE: (805) 562-0413
LICENSING EVALUATOR NAME: Rachael De LeonTELEPHONE: (805) 450-0262
LICENSING EVALUATOR SIGNATURE:
DATE: 11/16/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/16/2023
LIC809 (FAS) - (06/04)
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