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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801762
Report Date: 09/20/2023
Date Signed: 09/20/2023 03:36:00 PM


Document Has Been Signed on 09/20/2023 03:36 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 IIIFACILITY NUMBER:
565801762
ADMINISTRATOR:JOSEPH JOSEFACILITY TYPE:
740
ADDRESS:1446 SUFFOLK AVENUETELEPHONE:
(805) 496-9592
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 6DATE:
09/20/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Laila KulunguTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 09:58AM. LPA met with Facility Designee Laila Kulungu. Entrance interview conducted.

Beginning at 10:18AM, the LPA, along with Facility Designee toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

Fire extinguisher is fully charged and purchased on 08/03/2023. Hardwired combination smoke detectors and carbon monoxide detectors as well as separate carbon monoxide detectors were tested and were functional at the time of the visit. No fire clearance concerns were observed.

KITCHEN: The LPA observed the kitchen/dining area to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food. The LPA observed one designated drawer where knives and sharps are stored locked and inaccessible to residents. Cleaning supplies are located in a locked cabinet under the kitchen sink.

COMMON AREAS: This includes the living room, family room, and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. An adequately screened fireplace was noted in the living room.

LAUNDRY ROOM & GARAGE: The locked laundry room is located in the hallway adjacent to the family room. Laundry supplies and chemicals are stored in locked cabinets, inaccessible to residents in care. Garage was observed locked and contained extra food, PPE supplies, cleaning supplies, and emergency Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
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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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: 09/20/2023
NARRATIVE
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food and water supply.

BATHROOMS: There are three (3) bathrooms for resident use. Restrooms were observed to be equipped with nonskid surfaces and contain nonskid mats. Grab bars were observed in the bathrooms. The water temperature was measured in both shared resident bathrooms and measured in compliance with regulation.

BEDROOMS: There are seven (7) total bedrooms in the facility; six (6) bedrooms are designated for private resident use and one (1) staff room. The staff room is kept locked. All resident rooms were observed to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

OUTDOOR SPACE: The backyard has a covered patio area with patio furniture including a table and chairs for resident use. Facility has two total gates; both were observed to be self-latching and closing with clear passageways for emergency exit use. There were no bodies of water on the premises at the time of the visit. A locked shed was observed and is used for storage.

RECORD REVIEW: Began at 10:30AM (resident records) and 11:11AM (staff records.) Staff and resident records were reviewed for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisal, and personal rights. Two (2) of six (6) resident records reviewed (Resident #1 - R1 and Resident #2 - R2) have a dementia diagnosis and medical assessments were completed over a year ago. One (1) staff file reviewed did not contain proof of health screening and negative tuberculosis test. Additionally, LPA reviewed a letter issued to residents and/or their responsible persons dated 09/08/2022 indicating a pending change of ownership. The letter indicates that the Licensee entered into an Interim Management Agreement, which allows Sunshine Residential Home “to provide management and other services related to operation of the Omni facilities.” However, CCLD did not approve a change in management for the facility.

MEDICATION REVIEW: Began at 01:00PM. Medications for three (3) residents were observed. All medications observed were labeled, stored, and properly documented at the time of the visit.

Report Continued on LIC 809-C
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
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: 09/20/2023
NARRATIVE
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the
facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly, with the last drill conducted on 06/21/2023. Emergency disaster plan was last updated on 08/18/2023, but the outdated form was used, therefore pertinent information was not included in the update.

INTERVIEWS: During today's visit, LPA interviewed two (2) staff and three (3) residents.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 809-D.) The Facility Designee was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:

DATE: 09/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/20/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6
Document Has Been Signed on 09/20/2023 03:36 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: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87411(f)
Personnel Requirements - General
(f) All personnel, including the licensee and administrator, shall be in good health, and physically and mentally capable of performing assigned tasks.  Good physical health shall be verified by a health screening, including a chest x-ray or an intradermal test, performed by a physician not more than six (6) months prior to or seven (7) days after employment or licensure.  A report shall be made of each screening, signed by the examining physician.  The report shall indicate whether the person is physically qualified to perform the duties to be assigned, and whether he/she has any health condition that would create a hazard to him/herself, other staff members or residents.  A signed statement shall be obtained from each volunteer affirming that he/she is in good health.  Personnel with evidence of physical illness or emotional instability that poses a significant threat to the well-being of residents shall be relieved of their duties.

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 one (1) staff file reviewed (Staff #1 - S1) did not contain proof of health screening and tuberculosis test, which poses/posed a potential health and safetyrisk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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The Facility Designee indicated S1 will obtain a health screening and TB test prior to returning to work. Proof of health screeening and negative TB test will be sent to CCL 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/20/2023 03:36 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: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(a)
Other Provisions
(a) The administrator designated by the licensee pursuant to paragraph (11) of subdivision (a) of Section 1569.15 shall be present at the facility during normal working hours. A facility manager designated by the licensee with notice to the department, shall be responsible for the operation of the facility when the administrator is temporarily absent from the facility.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above as Administrator was not observed to be present at the facility, nor is approved Administrator on the LIC 500 provided, instead Facility Designee is listed as Administrator, but is not approved with CCL, which poses a potential health, safety and personal rights risk to persons in care.
POC Due Date: 09/27/2023
Plan of Correction
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Facility Designee agreed to send all documents to CCL to change Administrator by POC due date. Alternatively, a new LIC 500 may be provided listing the current Administrator's working hours and proof that Administrator is present at the facility during those designated hours by POC due date.
Type B
Section Cited
HSC
1569.695(a)
Other Provisions
(a) In addition to any other requirement of this chapter, a residential care facility for the elderly shall have an emergency and disaster plan that shall include, but not be limited to, all of the following:

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 as the previous LIC610E form is being used for the Emergency Disaster Plan which does not contain the required information and Emergency Binder provided was observed to be blank which poses a potential safety risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Facility Designee agreed to complete a new LIC 610E and provide proof to CCL 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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6


Document Has Been Signed on 09/20/2023 03:36 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: 09/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87705(c)(5)
87705 Care of Persons with Dementia (c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident’s dementia care needs.

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 2 residents (R1 & R2) files reviewed did not contain a current medical assessment and both residents have a dementia diagnosis, which poses a potential health and personal rights risk to persons in care.
POC Due Date: 10/04/2023
Plan of Correction
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Facility Designee agreed to obtain current medical assessments for both R1 and R2 and provide proof to CCL by POC due date.
Type B
Section Cited
HSC
1569.191(b)
§1569.191 Sale of licensed facility; resulting issuance of new license; procedure (b) Except as...the property and business shall not be transferred until the buyer qualifies for a license or provisional license within the appropriate provisions of this chapter.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on interview and record review, the Licensee did not comply with the above cited section, as the Licensee issued a letter to residents indicating an Interim Management Agreement is in place designating Sunshine Residential Home “to provide management and other services related to operation of the Omni facilities” that has not been approved by the Department, which poses a potential personal rights risk to residents in care.
POC Due Date: 10/04/2023
Plan of Correction
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Facility Designee agreed to contact Licensee and submit a statement of understanding related to Health & Safety Code 1569.191 to CCL by POC due date. Licensee can then determine whether an application to add a Management Company to the license is appropriate in this situation or if Licensee will maintain operations for the duration of time until the Change of Ownership application is approved.
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: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly DulekTELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:
DATE: 09/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/20/2023
LIC809 (FAS) - (06/04)
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