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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800734
Report Date: 02/14/2025
Date Signed: 02/14/2025 11:04:40 AM

Document Has Been Signed on 02/14/2025 11:04 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:HILLCREST ROYALEFACILITY NUMBER:
565800734
ADMINISTRATOR/
DIRECTOR:
INGA JAKOBOVICHFACILITY TYPE:
740
ADDRESS:190 EAST HILLCREST DRIVETELEPHONE:
(805) 371-0035
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 145CENSUS: 82DATE:
02/14/2025
TYPE OF VISIT:Case Management - Health ChecksUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:14 AM
MET WITH:Michelle Gubbay, Facility DesigneeTIME VISIT/
INSPECTION COMPLETED:
11:05 AM
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Licensing Program Analyst (LPA) Kelly Dulek made an unannounced case management visit to check the health and safety of residents in care following a reported smoke/fire incident at the facility that occurred yesterday 02/13/2025. LPA initially met with facility staff and explained the reason for today’s visit. Facility Designee Michelle Gubbay was contacted via telephone and arrived at 09:40AM, followed shortly thereafter by Designee Marian Rubenstein. Entrance interview conducted.

Yesterday, 02/13/2025 around 05:15PM, LPA was informed that there had been an incident at approximately 12:45PM involving a fire at the facility. LPA called the facility at 05:20PM on 02/13/2025 and gathered additional information from the Facility Designee. During today’s visit, LPA spoke with 2 (two) facility managers related to the incident. Management reported that the resident whose room was affected was not present at the facility at the time of the incident. Most residents were eating lunch in the facility dining rooms or otherwise out of their rooms. Incident report reviewed states that at approximately 01:00PM, the facility fire emergency system was activated by smoke from a resident’s apartment. Sprinkler system engaged and residents were evacuated from the building, following the facility’s emergency protocol. Management indicated that Ventura County Fire Department (VCFD) was contacted and arrived at the facility promptly. VCFD inspector informed the facility that the fire appeared to be electrical in nature and no foul play was suspected. Per interview with the facility management, only the 1 (one) resident was relocated to a vacant room. All other rooms were inspected by VCFD and cleared for resident use. Management indicated that water from the sprinkler system did affect the management office below, but no additional residents were affected.

During today’s visit at 10:08AM, LPA, along with Facility Designee, conducted a health and safety check tour of the facility and no concerns were observed. During the visit, fire alarm system representative was present inspecting the damage and observing the building electrical units to ensure safety of all residents in care. Facility management indicated the plan is to have all electrical inspected by a skilled professional to ensure there are no further incidents. A hard copy of the written incident report was provided to LPA during the visit.

No citations issued. Exit interview was conducted and a copy of this report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE: DATE: 02/14/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/14/2025
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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