565801947-10-19-2023-29-AS-MARO-CWRT3Q-20231019142244

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801947
Report Date: 10/19/2023
Date Signed: 10/19/2023 02:22:56 PM

Document Has Been Signed on 10/19/2023 02:22 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: 5	DATE:	10/19/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:25 AM
MET WITH:	Mirvat Yacoub / Tammy Frame		TIME COMPLETED:	02:30 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:25 a.m. The last annual conducted at this facility was on 10/18/2022. Upon arrival, there were two staff and five residents present. The Facility Manager, Tammy Frame arrived at 9:52 a.m. and at this time, the reason for the visit was explained. The Administrator, Mirvat Yacoub arrived during the inspection. Entrance interview conducted. At 9:52 a.m., the LPA along with the Facility Manager 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. KITCHEN: The LPA began the tour in the kitchen/food service area at 9:53 a.m. The hot water was measured at 106.8 degrees Fahrenheit at 9:55 a.m. The kitchen appeared clean and the appliances and fixtures functional. Refrigerated and frozen foods were stored at proper temperature. There was a sufficient amount of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. Food had labels clearly marked with dates. Knives and sharps were observed locked in a drawer next to the kitchen stove. Cleaning supplies were stored under the kitchen sink locked and inaccessible. There were no pesticides or poisons observed near any food areas. LIVING ROOM/DINING ROOM: The LPA inspected the living room and dining room area. The common areas were observed to be properly furnished and relatively clean at the time of the visit. Furniture was observed to be in good condition. Fireplace was observed to be adequately screened at the time of the visit. The facility maintained a comfortable temperature. (Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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: ENDURING OAKS ASSISTED LIVING, LLC	FACILITY NUMBER: 565801947
	VISIT DATE: 10/19/2023

NARRATIVE

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(Report Continued from LIC 809...)

At 10:15 a.m., the smoke detector(s) and carbon monoxide detectors were tested and operational. Fire extinguishers were observed fully charged and last serviced on 04/15/2023. The LPA observed required postings throughout the common spaces. The facility has a working telephone on premises. All doors were observed with functioning auditory alarms at the time of the visit. Entry/exits were free of obstruction.

GARAGE/BACKYARD: The garage is kept locked and inaccessible at all times. Washer and dryer are located inside the garage. The LPA observed another freezer in the garage with additional food. An adequate supply of emergency food and water was observed. The LPA observed a sufficient supply of Personal Protectant Equipment (PPE). Laundry detergents and toxins were observed in the garage inaccessible to residents in care. The backyard has a covered outdoor area equipped with furniture for resident use. The LPA observed one (1) gate with a self-latching mechanism and a clear passageway in case of an emergency. There were no bodies of water noted at the time of the visit.

BEDROOMS: There are four (4) resident bedrooms; two (2) single occupancy, and two (2) shared bedrooms. The LPA observed the resident bedrooms to be furnished appropriately with bedding and clean linens such as sheets, pillowcases, mattress pads, and blankets, and sufficient lighting. There is one (1) staff bedroom that is locked at all times. There is a closet in the main hallway with extra towels and linens.

BATHROOMS: There are two (2) bathrooms for resident use. Resident bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The hot water was measured in each bathroom; the first bathroom measured 109.9 degrees Fahrenheit at 10:00 a.m.; and the second bathroom measured 113.5 degrees Fahrenheit at 10:13 a.m.

RECORDS: Records review began at 10:18 a.m., five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

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: ENDURING OAKS ASSISTED LIVING, LLC	FACILITY NUMBER: 565801947
	VISIT DATE: 10/19/2023

NARRATIVE

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(Report Continued from LIC 809C...)

Three (3) Personnel records and Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

Emergency Disaster drills were conducted within the last 6 months as per regulation; the last one conducted 09/07/2023.

MEDICATIONS: Medications review began at approximately 12:25 p.m. Medications are centrally stored in a cabinet by the kitchen locked and inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No medication errors observed at this time.

During today’s visit, the LPA obtained copies of the following: LIC 500 Personnel Report, LIC 9020 Resident Roster, Emergency Disaster Plan, and a copy of limited liability insurance.

Exit interview conducted. No citations issued. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 10/19/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/19/2023

LIC809 (FAS) - (06/04)

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