565801851-2-26-2024-29-AS-ZCHN-D2TP39-20240226095707

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801851
Report Date: 02/20/2024
Date Signed: 02/26/2024 10:02:29 AM

Document Has Been Signed on 02/26/2024 10:02 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:	ROYAL OAKS HOME CARE		FACILITY NUMBER:	565801851
ADMINISTRATOR:	KAREN ROSALES		FACILITY TYPE:	740
ADDRESS:	1106 ROYAL AVENUE		TELEPHONE:	(805) 210-2757
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 6	DATE:	02/20/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:15 AM
MET WITH:	Karina Antig		TIME COMPLETED:	06:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with staff (2). Staff contacted back-up administrator Karina Antig, who arrived shortly after LPA. Reason for the visit was stated.

At approximately 11:45am, the LPA and administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. Smoke and carbon monoxide detectors tested and functioned properly during today's visit.

KITCHEN: Knives and cleaning supplies are stored in a locked cabinet. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications were stored in a locked cabinet . The door to the garage, which is in the kitchen observed locked during today's visit.
BEDROOMS: The LPA observed six single-occupancy client bedrooms which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting; and one staff room. RESTROOMS: Restrooms observed to be clean, sanitary and in operating condition; stocked with paper towels, toilet paper and soap. Restrooms observed with grab bars installed and shower mats. The facility had an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. COMMON SPACES: The living room, family room and dining room furniture were observed to be in good condition. The backyard patio is equipped with furniture for resident use.

Resident files reviewed for completeness and accuracy at approximately 12:30pm. Five (5) out of six (6) resident files did not have an updated Needs and Services Plan. Staff files reviewed at approximately 3pm Staff 1 and 2 did not have record of TB clearance; Initial required training for staff was not met; staff lacked medication shadowing and dementia care training hours. Resident Medication records reviewed at approximately 4pm - Medication records and procedures reviewed and observed to complete and accurate.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Exit interview conducted. Copy of report and appeal rights provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL OAKS HOME CARE	FACILITY NUMBER: 565801851
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87303(i)

Maintenance and Operation

(i) Facilities shall have signal systems which shall meet the following criteria: This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and interview, the licensee did not comply with the section cited above; the exit door alarms not working properly which poses/posed a potential health and safety risk to persons in care.
	POC Due Date: 02/21/2024
	Plan of Correction
1 2 3 4	Ms. Antig stated that the company will come out to fix the problem and ensure all exit door alarms are working properly. Submit a self-certification letter and work order invoice.

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interview and record review, the licensee did not comply with the section cited above in 2 out of 2 staff training records reviewed did not have proof of required training completed which poses a potential health and safety risk to persons in care.
	POC Due Date: 02/26/2024
	Plan of Correction
1 2 3 4	Ms. Antig stated that she will have staff required training completed for staff 1 and 2; will submit copyof the complete and accurate training record for staff 1 and 2 by plan of correction 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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

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: ROYAL OAKS HOME CARE	FACILITY NUMBER: 565801851
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.69(a)(2)

Other Provisions

(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff files reviewed; staff 1 and 2 did not recieve required shadowing and training hours to assist with medications. This poses a potential health, and safety risk to persons in care.
	POC Due Date: 02/26/2024
	Plan of Correction
1 2 3 4	Ms. Antig stated that she will prepare and dispense resident medication until staff 1 and 2 complete required medication training including shadowing provided by a skilled professional.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/26/2024 10:02 AM - 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: ROYAL OAKS HOME CARE	FACILITY NUMBER: 565801851
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87467(a)(3)

Resident Participation in Decisionmaking

(a) Prior to, or within two weeks of the resident's admission, the licensee shall arrange a meeting with the resident, the resident's representative, if any, appropriate facility staff, and a representative of the resident's home health agency, if any, and any other appropriate parties, to prepare a written record of the care the resident will receive in the facility, and the resident's preferences regarding the services provided at the facility. (3) The licensee shall arrange a meeting with the resident and appropriate individuals identified in Section 87467(a)(1) to review and revise the written record as specified, when there is a significant change in the resident's condition, or once every 12 months, whichever occurs first. Significant changes shall include, but not be limited to occurrences specified in Section 87463, Reappraisals. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 5 out of 6 resident files reviewed; R1,2,3,4,5 did not have a completed needs and services plan. This poses a potential health, safety and personal rights risk to persons in care.
	POC Due Date: 02/23/2024
	Plan of Correction
1 2 3 4	Ms. Antig stated she will complete the needs and services plan for R1,2,3,4, and 5; ensure it is reviewed and signed by all parties. Submit copies to CCL by POC 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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/26/2024 10:02 AM - 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: ROYAL OAKS HOME CARE	FACILITY NUMBER: 565801851
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/20/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87705(c)(3)(A)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (3) In addition to the on-the-job training requirements in Section 87411(d), staff who provide direct care to residents with dementia shall receive the following training as appropriate for the job assigned and as evidenced by safe and effective job performance: (A) Dementia care including, but not limited to, knowledge about hydration, skin care, communication, therapeutic activities, behavioral challenges, the environment, and assisting with activities of daily living; This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 2 out of 2 staff files reviewed; staff which poses/posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 02/26/2024
	Plan of Correction
1 2 3 4	Ms. Antig stated she will ensure all training requirement ae met for staff 1 and 2; Ms. Anitg will submit proof of training hours are complete according to regulation for staff 1 and 2. Submit records of training hours for staff 1 and 2 by POC date.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 02/20/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/20/2024

LIC809 (FAS) - (06/04)

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