565801947-10-18-2022-29-AS-KDUK-CKBUM3-20221018154140

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801947
Report Date: 10/18/2022
Date Signed: 10/18/2022 03:42:22 PM

Document Has Been Signed on 10/18/2022 03:42 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:	ENDURING OAKS ASSISTED LIVING, LLC		FACILITY NUMBER:	565801947
ADMINISTRATOR:	MIRVAT YACOUB		FACILITY TYPE:	740
ADDRESS:	4264 COLIBRI COURT		TELEPHONE:	(805) 530-3818
CITY:	MOORPARK	STATE: CA	ZIP CODE:	93021
CAPACITY:	6	CENSUS: 3	DATE:	10/18/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:06 PM
MET WITH:	Mirvat Yacoub & Anna Fabregas		TIME COMPLETED:	03:42 PM

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 12:06PM. This annual had a specific emphasis on infection control practices and procedures. LPA initially met with facility staff Hilda Alvarado. Licensee Mirvat Yacoub was contacted via telephone and arrived at the facility at 12:33PM. Entrance interview conducted.

The LPA, along with Licensee, toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed:

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, family room, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings in the common area.

The backyard has a covered outdoor area equipped with furniture for resident use. There were no bodies of water noted. Garage contained the laundry area, as well as emergency food supply, and storage.

KITCHEN: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. All knives and cleaning supplies were observed to be locked and properly stored at the time of the visit.

BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are 5 (five) total bedrooms; 4 (four) are for resident use and 1 (one) is designated as a staff room.

RESTROOMS: The LPA observed 2 restrooms in the facility; one is a shared resident restroom and one is a private resident restroom. Resident restrooms are clean and sanitary and in operating condition with grab Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

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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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
	VISIT DATE: 10/18/2022

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bars and non-skid surfaces. Water temperature was checked in resident restrooms and at 12:37PM water in the shared resident restroom measured at 125.4 degrees Fahrenheit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Consultant regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening. LPA observed all staff and visitors to be wearing masks. The LPA observed an adequate supply of Personal Protective Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility’s policies and procedures as it pertains to infection control are adequate.

RECORD REVIEW: Began at 12:16PM. LPA observed 2 staff working in the facility. Staff #1 (S1) indicated they have been working at the facility for over 6 months. Review of the Guardian background system revealed S1 does not have fingerprint clearance associated to the facility

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 conducted with Consultant/Designee Anna Fabregas. Today’s reports and appeal rights were reviewed and provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/18/2022 03:42 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: ENDURING OAKS ASSISTED LIVING, LLC	FACILITY NUMBER: 565801947
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/18/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87303(e)(2)

87303 Maintenance and Operation (e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degree C) and not more than 120 degree F (49 degree C). 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 at 12:37PM the water temperature in the resident restroom measured at 125.4 degrees Fahrenheit which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/26/2022
	Plan of Correction
1 2 3 4	Licensee turned down the hot water heater during today's visit. Licensee will record daily water temperatures for a week and submit to CCL by 10/26/2022.

Type A

Section Cited

CCR

87355(e)(2)

87355 Criminal Record Clearance (e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: (2) Request a transfer of a criminal record clearance as specified in Section 87355(c) 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 in Staff #1 (S1) has been employed by the facility for over 6 months and Guardian review revealed S1 did not have a clearance transfer, which poses an immediate safety risk to persons in care.
	POC Due Date: 10/18/2022
	Plan of Correction
1 2 3 4	S1 was removed from the facility during the visit. S1 was taken and fingerprinted again during today's visit. Licensee will ensure S1 is associated in Guardian prior to returning to the facility.

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 Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 10/18/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2022

LIC809 (FAS) - (06/04)

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