565801762-8-22-2022-29-AS-ASMH-CHJVYK-20220822165117

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801762
Report Date: 08/22/2022
Date Signed: 08/22/2022 04:52:49 PM

Document Has Been Signed on 08/22/2022 04:52 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:	OMNICARE III		FACILITY NUMBER:	565801762
ADMINISTRATOR:	KINGA KOZDRON		FACILITY TYPE:	740
ADDRESS:	1446 SUFFOLK AVENUE		TELEPHONE:	(805) 496-9592
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 6	DATE:	08/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:45 PM
MET WITH:	Kinga Kozdron		TIME COMPLETED:	04:00 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 (LPA) Ashley Smith arrived unannounced to conduct a required annual visit. This annual had a specific emphasis on infection control practices. The LPA initially met with staff, whom contacted the Administrator. Administrator Kinga Kozdron arrived shortly thereafter and the LPA explained the reason for the visit. The LPA, along with staff, toured the facility to ensure there were no immediate health and safety hazards. The LPA spoke with residents during the tour; residents appeared well kept and no concerns were communicated. KITCHEN: Knives and chemicals are locked inaccessible. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: There are seven rooms total; six private resident rooms and one designated staff room. Bedrooms had appropriate furniture, clean linens and sufficient lighting. Rooms were clean and clear of obstructions. RESTROOMS: The three restrooms were clean and sanitary with grab bars and non-skid surfaces. At 3:15 p.m., water temperature measured at 105 F. Restrooms were stocked with soap and paper towels. COMMON SPACES: The facility maintained a temperature of 75 degrees. Medications were kept locked in a hallway cabinet, which also had additional supplies. Smoke detectors and carbon monoxide detectors were operable. Living room and dining furniture were observed in good condition. Fire extinguisher was serviced August 2022. The backyard and exterior area of the facility had furniture and a covered area for resident use. No obstructions observed in the exterior or interior. No bodies of water noted. The garage is attached, is kept locked and was equipped with a large supply of Personal Protection Equipment (PPE). Additional food was observed in the garage in good condition.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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 08/22/2022 04:52 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: OMNICARE III	FACILITY NUMBER: 565801762
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 08/22/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87468.1(a)(2)

Personal Rights of Residents in all Facilities

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as staff were observed not wearing appropriate face coverings and did not ask COVID-19 screening questions upon the LPA's arrival, which poses a potential personal rights risk to persons in care.
	POC Due Date: 08/22/2022
	Plan of Correction
1 2 3 4	The Administrator issued corrective action to staff during today's visit. Staff communicated understanding of the protocol. During today's visit, a notice was posted by the front door, detailing the steps. Plan of Correction met at this time.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

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: OMNICARE III	FACILITY NUMBER: 565801762
	VISIT DATE: 08/22/2022

NARRATIVE

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INFECTION CONTROL: Upon entry, the staff member whom answered the door was not wearing an appropriate face covering. In addition, the staff did not ask the LPA the screening questions nor did they take the LPA's temperature. This was brought to the Administrator’s attention, whom provided immediate guidance and training to the staff in the moment. Staff communicated understanding of the procedure.

There is a central entry point for screening and temperature checks. The facility’s cleaning protocol is sufficient. There is record of staff and resident vaccinations. The facility can designate a room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines around visitation and vaccine requirements. The facility has submitted an up-to-date Infection Control Plan. Staff have recently been trained on COVID-19 protocol and the monkey-pox epidemic. The policies and procedures pertaining to infection control were adequate.

The following deficiencies were observed (See LIC 809-D.) and cited from the CA Code of Regulations, Title 22. Exit interview conducted. A copy of the report was issued, along with appeal rights.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 08/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/22/2022

LIC809 (FAS) - (06/04)

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