565801851-2-3-2023-29-AS-TCAA-CNPRZ6-20230203122724

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801851
Report Date: 02/03/2023
Date Signed: 02/03/2023 12:29:00 PM

Document Has Been Signed on 02/03/2023 12:29 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:	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:	02/03/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:35 AM
MET WITH:	Karina Antig		TIME COMPLETED:	12:40 PM

NARRATIVE

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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 09:35 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with back-up Administrator Karina Antig and explained the reason for the visit.

The LPA 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. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher appeared fully charged and was purchased 5/10/22..

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 was unlocked; laundry detergent, cleaning supplies (Pinesol, Clorox) were accessible; Staff 2 (S2) locked the garage door during the visit.

BEDROOMS: The LPA observed four single-occupancy client bedrooms and one double-occupancy bedroom which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The staff room was open and there were vitamins unsecured in the room; Staff 1 (S1) locked the door during the visit.

RESTROOMS: Restrooms are clean and sanitary and in operating condition. LPA observed two pair of scissors in unlocked drawers in one of the hall bathrooms; S1 locked the scissors in the bathroom cabinet during the visit.

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.

continued on 809-C

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

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: ROYAL OAKS HOME CARE	FACILITY NUMBER: 565801851
	VISIT DATE: 02/03/2023

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continued from 809

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. Staff were wearing masks. Infection control postings were observed.. The facility had an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Today's reports and appeal rights were discussed and report was emailed to the administrator.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE:	DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 02/03/2023 12:29 PM - It Cannot Be Edited

Created By: Teresa Camara On 02/03/2023 at 11:53 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL OAKS HOME CARE	FACILITY NUMBER: 565801851
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 02/03/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above as there were two pairs of scissors found in two unlocked drawers in the hall bathroom, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2023
	Plan of Correction
1 2 3 4	Staff removed the scissors and placed them in a locked cabinet in the bathroom. Administrator will conduct training with all staff regarding keeping dangerous items inaccessible to residents. Administrator will provide evidence of this training to CCL on or before 02/10/2023.

Type A

Section Cited

CCR

87705(f)(2)

87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA's observations, the licensee did not comply with the section cited above as vitamins were observed in the open staff room and cleaning supplies were observed in the open garage adjacent to the kitchen, which poses an immediate health, safety or personal rights risk to persons in care.
	POC Due Date: 02/10/2023
	Plan of Correction
1 2 3 4	Staff locked the staff room and garage door making the viatmins and cleaning supplies inaccssible. Administrator will conduct training with all staff regarding keeping dangerous items inaccessible to residents. Administrator will provide evidence of this training to CCL on or before 02/10/2023.

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

LICENSING EVALUATOR NAME:

Teresa Camara

LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2023

LIC809 (FAS) - (06/04)

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