565850203-9-16-2021-29-AS-MGCZ-C6WPC2-20210916111113

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850203
Report Date: 09/16/2021
Date Signed: 09/16/2021 11:11:58 AM

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:	GEM OAKS		FACILITY NUMBER:	565850203
ADMINISTRATOR:	SABYROVA, ELMIRA		FACILITY TYPE:	740
ADDRESS:	1060 CALLE LAS TRANCAS		TELEPHONE:	(818) 284-8422
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY:	6	CENSUS: 0	DATE:	09/16/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Elmira Sabyrova		TIME COMPLETED:	11:10 AM

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 Guzman Chavez conducted an announced pre-licensing visit to this property at 8:00am on 09-16-2021 and met with applicant representative Elmira Sabyrova. Entrance interview conducted. The applicant has obtained fire clearance for a total capacity of 1 (one) bedridden and 5 (five) non-ambulatory for a total capacity of six (6) clients. Facility has six (6) bedrooms and 3.5 bathrooms. One bedroom is for double occupancy. The smoke detectors and carbon monoxide detector were tested and were operational. LPA observed one (1) fire extinguisher to be fully charged by the kitchen. The facility has emergency lighting throughout the hallways. LPA observed the first aid kit and manual to be complete with bandages, scissors, tweezers, gauze, and a thermometer. The common living and dining areas are clean and properly furnished with seating for future residents. Facility has a working landline telephone. All six (6) exit doors have functioning auditory alarms. All bedroom, bathroom, kitchen, and common areas windows have clean window coverings with screens and in good repair. Appliances in the kitchen were clean and all appeared functional. Hot water at the kitchen sink measured at 114.8 degrees Fahrenheit. LPA observed a sufficient supply of at least seven (7) non-perishable and two (2) days perishable foods. LPA observed a locked cabinet under the kitchen sink where chemicals will be stored. Also, one designated drawer next to the kitchen sink was observed locked, containing knives and sharps. Medications will be locked in cabinet next to the kitchen. Facility records will be locked in a file cabinet by the hallway. Hallways were free of any obstruction. LPA observed a laundry room with a locked door, which will always remain locked inaccessible to future residents. There are five (5) resident bedrooms that were properly furnished. Each bedroom had a bed with clean linens, a television, a nightstand, and adequate lighting. There are three (3) bathrooms for resident use. Bathrooms were measure for hot water, first bathroom measured at 116.6 degrees Fahrenheit, second bathroom measured at 118.4 degrees Fahrenheit, and third bathroom measured at 113 degrees Fahrenheit. Each bathroom was adequately equipped with toilet paper and paper towels, as well as with grab bars and non-skid mats inside the showers. ...(Continued on LIC 809c)

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

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: GEM OAKS	FACILITY NUMBER: 565850203
	VISIT DATE: 09/16/2021

NARRATIVE

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...(Continued from LIC 809)

The backyard has a covered patio area with a table and chairs for future resident use. LPA observed a small vegetable garden on the side for gardening activities for future residents. Facility has two (2) ramps in the backyard, wheelchair friendly. LPA observed two (2) fence gates that self-latch with clear passageways for emergency exit use. LPA observed a locked storage shed in the back yard. There are no bodies of water on the premises at the time of the visit.

No CDSS PINs posted up yet, but facility does have Personal Rights, Complaint Poster (PUB 475) Emergency Exit Plan, and list of Emergency Phone Numbers if needed.

Comp III was completed in conjunction with the visit.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. A copy of this report will be forwarded to the application specialist with LPA's recommendation for licensure. An exit interview was conducted with Administrator, and a hard copy was provided via email.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Guzman-Chavez	TELEPHONE: (818) 596-4334
LICENSING EVALUATOR SIGNATURE:	DATE: 09/16/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/16/2021

LIC809 (FAS) - (06/04)

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