565801947-9-23-2024-29-AS-VCOY-D9DL2E-20240923082209

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565801947
Report Date: 09/21/2024
Date Signed: 09/23/2024 08:22:23 AM

Document Has Been Signed on 09/23/2024 08:22 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
WOODLAND HILLS N.ASC, 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: 4	DATE:	09/21/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Assistant Admin Tammy Frame		TIME COMPLETED:	02:45 PM

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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit at 9:45 A.M. Upon arrival LPA met with caregiver, Veaarrahria “Vea” Vicedo who called Administrator via phone. At 10:12 A.M., Assistant Administrator Tammy Frame arrived at the facility. Assistant Administrator stated that Administrator, Mirvat Yacoub, was not able to be present at the time of the visit, however, Assistant Administrator is authorized to sign today’s report. LPA explained reason for visit. The last annual conducted at this facility was on 10/19/2023. Upon arrival, there were two staff members, and four residents present. Entrance interview conducted.

Starting at 10:15 A.M., the LPA, along with Assistant Administrator, 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:

Bedrooms: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are four (4) total bedrooms, two (2) shared and two (2) private, and one (1) staff room. Room #2 is cleared as a bedridden room. LPA observed that Room #2 is equipped with a fire door, and it has a direct exit to the backyard in case of an emergency. At the time of the visit, LPA observed fire door held open with a magnetic door holder and working when smoke alarm test was conducted. No bedroom was used as a passageway to another room, bath, or toilet. All rooms were free of odors. All window screens were clean and maintained in good repair.

Continues on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ENDURING OAKS ASSISTED LIVING, LLC	FACILITY NUMBER: 565801947
	VISIT DATE: 09/21/2024

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Continued from LIC 809

Bathrooms: The LPA observed two (2) bathrooms. One (1) shared and one (1) in the master room, Room #1. Resident bathrooms were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces. All bathrooms were supplied with appropriate paper and hygiene products. Between 10:17 A.M. and 10:25 A.M., hot water temperatures were measured in all resident bathrooms and measured within the required range of 105 degrees Fahrenheit to 120 degrees Fahrenheit at the time of the visit.

Outdoor Space: The backyard area contains a shaded area with a table and chairs for resident use. There is one (1) side gate with self-latching mechanism and a working alarm. Passageways were observed to be clear and free of hazards. There were no bodies of water noted at the time of the visit.

Kitchen: Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food at the time of the visit. Food labels were inspected and checked for dates and expiration dates. Refrigerated and frozen foods were stored at proper temperature. There was sufficient dining and cook ware to accommodate a maximum capacity of 6 residents. 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. There were no visible immediate hazards observed. At 12:25 P.M. hot water temperature measured at 114.1 degrees Fahrenheit. Fire extinguisher is fully charged, and recently serviced on 04/15/2024. Combination smoke alarms and carbon monoxide detectors were tested at 12:15 P.M. and were operational at this time.

Common spaces: 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. The LPA observed the required postings in the common area. The facility maintained a comfortable temperature of 75 degrees. Facility provides sufficient space to accommodate both indoor and outdoor activities. LPA observed a working phone available for residents use whenever needed. There is a fireplace in the Living Room, which was observed to be adequately screened. During today’s inspection, LPA observed, fire door held open with a magnetic door holder, separating the common areas and kitchen from bedrooms and bathrooms. All exit doors were observed with functioning auditory alarms at the time of the visit. Continues on LIC 809-C

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ENDURING OAKS ASSISTED LIVING, LLC	FACILITY NUMBER: 565801947
	VISIT DATE: 09/21/2024

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Continued from LIC 809-C

Garage/Office: The garage is kept locked and inaccessible at all times. The garage is where the washer and dryer are held. Cleaning supplies and disinfectants are kept in locked cabinets in the garage all cleaning compounds were stored in areas separately from food supplies. The LPA observed another freezer in the garage with additional food. An adequate supply of emergency food and water was observed. In the garage there is an office area. Next to the office desk, there is a locked file cabinet where both staff and resident files are securely stored.

File review: A review of facility files was initiate at 11:15 A.M. and the following was observed. LPA reviewed four (4) residents files were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were in order at this time.

At 11:46 A.M. four (4) personnel records including Administrator and Assistant Administrators’ files 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.

During today’s visit, the LPA obtained copies of the following: LIC 500 Personnel Report, LIC 9020 Resident Roster, and a copy of limited liability insurance. Last emergency disaster drill for wildfire was conducted on 07/10/2024 and 07/12/2024,

Medication review: Medications are centrally stored in a cabinet by the kitchen locked and inaccessible to residents in care. Medication review began at 1:10 P.M.; LPA reviewed medication log for all four (4) residents. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

No deficiencies cited at this time. Exit interview conducted. Report issued and provided to Assistant Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Valeria Conway	TELEPHONE: (818) 454-0485
LICENSING EVALUATOR SIGNATURE:	DATE: 09/21/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2024

LIC809 (FAS) - (06/04)

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