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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801947
Report Date: 02/02/2022
Date Signed: 02/02/2022 03:00:07 PM

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:ENDURING OAKS ASSISTED LIVING, LLCFACILITY NUMBER:
565801947
ADMINISTRATOR:MIRVAT YACOUBFACILITY TYPE:
740
ADDRESS:4264 COLIBRI COURTTELEPHONE:
(805) 530-3818
CITY:MOORPARKSTATE: CAZIP CODE:
93021
CAPACITY:6CENSUS: 6DATE:
02/02/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
10:23 AM
MET WITH:Mirvat YacoubTIME COMPLETED:
01:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) JoAnn Rosales conducted a Case Management - Deficiencies visit at the facility. LPA met with Administrator Mirvat Yacoub.

During initial entry screening with staff Mangacop at 10:26 am LPA observed Clorox disinfecting wipes on a table in the living room accessible to residents. During facility tour with Administrator at 10:28 am LPA observed laundry detergent, laundry sanitizer bleach, toilet bowl cleaner, wood cleaner, hardwood floor cleaner, liquid plumr, fabuloso multi purpose cleaner in an unlocked cabinet in the garage accessible to residents as the door leading into the garage was left propped open. Administrator stated that they keep the door locked when they are not in the garage. During facility tour with Administrator at 10:33 am LPA observed dish soap on kitchen counter sink and knives and scissors in a kitchen drawer that were accessible to residents. Administrator stated that they notified their maintenance person today that the lock was not working properly. A review of all resident records starting at 11:38 am revealed that all 6 residents in the facility are at risk based on their diagnosis.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview was conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:

DATE: 02/02/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/02/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 2
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: ENDURING OAKS ASSISTED LIVING, LLC
FACILITY NUMBER: 565801947
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/02/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/02/2022
Section Cited

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87705 Care of Persons with Dementia(f)(1) The following shall be stored inaccessible to residents with dementia: Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s).

This requirement is not met as evidenced by:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as knives and scissors were observed accessible to residents which posed an immediate safety risk to persons in care.
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Type A
02/02/2022
Section Cited

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87705 Care of Persons with Dementia (f)(2) The following shall be stored inaccessible to residents with dementia: 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:
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Based on LPA's observations and record review, the licensee did not comply with the section cited above as toxic substances were observed accessible to residents which posed an immediate health risk to persons in care.
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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: Joann RosalesTELEPHONE: (626) 419-4072
LICENSING EVALUATOR SIGNATURE:
DATE: 02/02/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/02/2022
LIC809 (FAS) - (06/04)
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