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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850203
Report Date: 09/13/2023
Date Signed: 09/13/2023 03:51:46 PM


Document Has Been Signed on 09/13/2023 03:51 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 OAKSFACILITY NUMBER:
565850203
ADMINISTRATOR:SABYROVA, ELMIRAFACILITY TYPE:
740
ADDRESS:1060 CALLE LAS TRANCASTELEPHONE:
(818) 284-8422
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 5DATE:
09/13/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:20 AM
MET WITH:Elmira SabyrovaTIME COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 10:20 a.m. The LPA was greeted by staff and explained the reason for the visit. Administrator Elmira Sabyrova arrived shortly thereafter.

At 10:45 a.m. the LPA and staff 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 inspected the kitchen and food area at 10:45 a.m. Knives and sharps were observed in a locked drawer next to the stove. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates. At 10:49 a.m. the LPA discovered the following expired items in the refrigerator, expired cabbage, bell pepper, milk expired 9/2/23 and 9/3/2023, Parmesan cheese expired 12/30/2022, pickles expired 4/2/2023, cheese expired 9/6/2023, cream cheese expired 4/16/2023 and 6/4/2023. Staff disposed of all expired items at the time of the visit. The LPA also discovered unlocked refrigerated medications. LPA advised Administrator that refrigerated medications need to be kept in a lock box.

Common areas: Living and dining room furniture were observed to be in good condition. At 12:00 p.m., smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The LPA observed required postings throughout the common space. The fire extinguisher was observed and last purchased on 12/27/2021. Administrator advised they would replace the fire extinguisher immediately. The laundry room is located in the main hallway and is locked and inaccessible. The garage is attached to the facility and is locked and inaccessible. The facility has a sufficient amount of emergency water and food supplies.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
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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Document Has Been Signed on 09/13/2023 03:51 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Section Cited
Maintenance and Operation
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as multiple food items were identified to be expired which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/14/2023
Plan of Correction
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The Adminsitrator agreed to the following:
1. Discard of all discovered expired food items. Plan of correction met at the time of the visit.
2. Conduct a full audit of all foods and replace and discard any items that are expired.
Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/13/2023 03:51 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as cleaning supplies, over the counter medications, vitamins and refrigerated medications were observed accesible which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/14/2023
Plan of Correction
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The adminstrator agreed to the following:
1. Secure all accessible items. Provide proof to CCL no later than 9/14/2023.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
LIC809 (FAS) - (06/04)
Page: 3 of 6


Document Has Been Signed on 09/13/2023 03:51 PM - It Cannot Be Edited

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

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/13/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above as faucets delivering hot water in bathrooms were delivering water about 120 degrees F which poses an immediate health and safety risk to persons in care.
POC Due Date: 09/14/2023
Plan of Correction
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The administrator agreed to the following:
1. Adjust the water temperature to ensure taps are delivering water between 105 and 120 degress F. Plan of correction met at the time of the visit.
Section Cited
Deficient Practice Statement
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4
POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2023
LIC809 (FAS) - (06/04)
Page: 4 of 6


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: 09/13/2023
NARRATIVE
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(Report Continued from LIC 809...)

Outdoor: There are 3 sheds in backyard that are used for storage. The backyard has a covered outdoor area equipped with furniture for client use. The LPA observed two side gates that are self-closing and latched. Passageways were observed clear of obstructions in case of an emergency. No bodies of water noted at the time of visit.

Restrooms: The client restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. At 11:11 a.m. the LPA observed unlocked cleaning supplies, powdered bleach and disinfecting wipes. The hot water temperature was measured in all bathrooms; water measured at 122.5 to 128.6 degrees Fahrenheit between 11:33 a.m. and 11: 42 a.m. The administrator adjusted the water temperature at the time of the visit. Water temperature read 120 degrees Fahrenheit at 3:22 p.m.

Bedrooms: There are five (5) private resident bedrooms, which were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed. There is one (1) staff room which was locked. At 11:17 a.m. the LPA observed unlocked cough syrup in bedroom # 4.

RECORD REVIEW: Residents’ records review began at 12:45 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

(Report Continued on LIC 809C...)

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
Page: 5 of 6
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: 09/13/2023
NARRATIVE
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(Report Continued from LIC 809C...)

MEDICATIONS: Medications review began at 1:45 p.m.; medications are centrally stored and locked in a mediation cabinet in the kitchen; 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.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2023
LIC809 (FAS) - (06/04)
Page: 6 of 6