565850203-9-26-2022-29-AS-MARO-CJMQHK-20220926121116

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850203
Report Date: 09/26/2022
Date Signed: 09/26/2022 12:12:21 PM

Document Has Been Signed on 09/26/2022 12:12 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:	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: 5	DATE:	09/26/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:30 AM
MET WITH:	Elmira Sabyrova		TIME COMPLETED:	12:15 PM

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Licensing Program Analyst (LPA), Martha Arroyo conducted an unannounced visit to Gem Oaks to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 10:30 a.m. This will be the first Annual from their Pre-Licensing visit on 9/16/2021. The LPA was greeted and screened at the door by Licensee, Elmira Sabyrova and the reason for the visit was explained. Entrance interview.

At 10:34 a.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed two (2) designated drawers in the kitchen where knives and sharps are locked and inaccessible to residents. Medications were observed locked in a cabinet adjacent to the kitchen.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. Bathrooms were measured for hot water, the first bathroom measured at 118.4 degrees Fahrenheit at 10:36 a.m. and the second bathroom measured at 110.7 degrees Fahrenheit at 10:39 a.m.

…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: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

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: GEM OAKS	FACILITY NUMBER: 565850203
	VISIT DATE: 09/26/2022

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…Report Continued from LIC 809...

GARAGE AND GROUNDS: The garage is locked and attached to the house. LPA observed one (1) additional refrigerator stocked at the time of visit. The laundry room is locked and inaccessible to residents in care. Cleaning supplies and chemicals are stored and inaccessible inside the laundry room. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed one (1) resident in the living room watching television. Fire extinguisher was observed and purchased on 12/27/2021.

During today’s visit, the LPA spoke with the Licensee regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff are fully vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

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

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 09/26/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/26/2022

LIC809 (FAS) - (06/04)

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