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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850108
Report Date: 06/20/2024
Date Signed: 06/20/2024 04:34:13 PM


Document Has Been Signed on 06/20/2024 04:34 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:OAK PLACE RESIDENTIAL CAREFACILITY NUMBER:
565850108
ADMINISTRATOR:SPRING, BECKYFACILITY TYPE:
740
ADDRESS:50 OAK ST.TELEPHONE:
(805) 586-4086
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY:36CENSUS: 36DATE:
06/20/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:15 AM
MET WITH:Becky SpringTIME COMPLETED:
02:45 PM
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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit. LPA met with Program Manager/Administrator Becky Spring and facility Designee Flordeliza (Baby) Hipolito and explained the reason for today’s visit. Entrance interview conducted.

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.

BEDROOMS: Resident bedrooms appeared to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are twenty total bedrooms, all of which were observed during the facility tour; four are private resident rooms and sixteen are shared resident rooms. Carbon monoxide detectors were observed in each room; randomly chosen detectors were tested and functioned properly.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom. Water temperature was tested in a sampling of resident restrooms, which was measured at 108 - 108.5 degrees Fahrenheit, which is within the required range.

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



Fire extinguishers were observed to be fully charged and last serviced on 9/1/2023. Fire inspections are conducted annually by Integrated Fire Safety (IFS). The last inspection was conducted on 2/9/2023. A

Continued on LIC 809-C
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/20/2024
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: OAK PLACE RESIDENTIAL CARE
FACILITY NUMBER: 565850108
VISIT DATE: 06/20/2024
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(continued from LIC809)

defective smoke/heat detector was replaced at that time; no other concerns were noted. IFS also conducted the facility's five-year inspection of the fire sprinkler system on 2/9/2023 with no concerns noted. An annual fire inspection by IFS for 2024 is scheduled for 6/27/2024. The fire department will be coming next week to conduct their required inspection as well.

The temperature inside the facility was maintained at a comfortable level throughout today's visit. Cleaning supplies and disinfectants are stored locked per regulation. The LPA observed cameras in the common areas. A working telephone is present.

KITCHEN: LPA observed the kitchen/dining area. Kitchen appliances appear to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food, including emergency supply and water. Cook stated that the facility uses Sysco for their food supply and delivery takes place every Tuesday. All knives and cleaning supplies were observed to be locked and stored in compliance with regulation.

OUTDOOR SPACE: The outdoor area has two covered outdoor seating areas equipped with furniture for residents' use. An outdoor space is designated for smoking. There were no bodies of water observed.

RECORD REVIEW: LPA reviewed staff and resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. The five staff files reviewed contained all documents. Separate training binder is maintained for all staff training. All five residents' files reviewed were in compliance.

MEDICATION REVIEW: LPA reviewed medications for randomly chosen residents. All medications were properly documented and appeared to be given as prescribed.

INTERVIEWS: LPA interviewed three staff and three residents; no concerns were noted.

No deficiencies cited. Exit interview conducted with Facility Designee. A copy of the report was provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 593-4347
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:

DATE: 06/20/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/20/2024
LIC809 (FAS) - (06/04)
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