565850203-9-10-2024-29-AS-KDUK-D8YVEU-20240910162255

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850203
Report Date: 09/10/2024
Date Signed: 09/10/2024 04:23:05 PM

Document Has Been Signed on 09/10/2024 04:23 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: 4	DATE:	09/10/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	11:27 AM
MET WITH:	Elmira (Emma) Sabyrova		TIME COMPLETED:	04:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a required annual visit at 11:27AM. The LPA was greeted by staff and explained the reason for the visit. Facilty Designee Ernis Sabyrov arrived shortly thereafter. Administrator Elmira (Emma) Sabyrova arrived at approximately 01:00PM.

Beginning at 11:52AM, the LPA and Facility Designee 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:

Fire extinguisher was observed to be fully charged and purchased on 09/13/2023. Hardwired combination smoke and carbon monoxide detectors were tested at 02:30PM and were operational at the time of the visit.

KITCHEN: Knives and sharps were observed in a locked drawer next to the stove. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food and a locked refrigerated medication box.

COMMON AREAS: Living and dining room furniture were observed to be in good condition. The LPA observed required postings throughout the common space. The garage is attached to the facility and is locked and inaccessible. Garage contains laundry facilities, extra food, cleaning supplies and emergency food and water.

RESTROOMS: The resident 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. The hot water temperature was measured in a sample of bathrooms and was within the required range.

BEDROOMS: There are 6 (six) private resident bedrooms, which were furnished with appropriate linens and

Report Continued on LIC 809-C

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: GEM OAKS	FACILITY NUMBER: 565850203
	VISIT DATE: 09/10/2024

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Continued from LIC 809

required furniture. Adequate lighting in all bedrooms was observed. There is 1 (one) staff room which was locked.

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

RECORD REVIEW: Record review began at 12:20PM. Resident records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. 1 (one) resident (Resident #1 - R1) with a diagnosis of dementia had a medical assessment dated 04/17/2023 and a needs and service appraisal dated 04/21/2023. Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All staff files were in order.

MEDICATIONS: Medications review began at 02:55PM; 2 (two) residents' medications were observed. Medications are centrally stored and locked in a mediation cabinet in the kitchen. Medications are documented on the centrally stored medications and destruction record. LPA observed that both residents had medications that had recent changes in orders. Based on the change in orders and days elapsed since the changes, both residents medication counts did not match the amount that should have been distributed.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control plan and emergency disaster plan. Both documents were observed to be complete and updated annually as required. Emergency disaster drills are conducted quarterly, with the last documented drill on 05/22/2024.

INTERVIEWS: During the visit, LPA interviewed 3 (three) staff and 1 (one) resident. No concerns noted.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and/or 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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/10/2024 04:23 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: 09/10/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(a)(4)

Incidental Medical and Dental Care Services

(4) The licensee shall assist residents with self-administered medications as needed. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and record review, the licensee did not comply with the section cited above as one medication for each resident (of 2 reviewed) was observed to have a change in orders and the amount of medications distributed did not match the days elapsed since the orders changed, which poses a potential health risk to persons in care.
	POC Due Date: 09/24/2024
	Plan of Correction
1 2 3 4	Administrator agreed to audit all medications and physician's orders to ensure there are no additional inconsistencies and that all inconsistencies identified are corrected. Proof of audit/corrections to be submitted to CCL by POC due date.

Type B

Section Cited

CCR

87705(c)(5)

Care of Persons with Dementia

(c) Licensees who accept and retain residents with dementia shall be responsible for ensuring the following: (5) Each resident with dementia shall have an annual medical assessment as specified in Section 87458, Medical Assessment, and a reappraisal done at least annually, both of which shall include a reassessment of the resident's dementia care needs. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on record review, the licensee did not comply with the section cited above in 1 (one) resident with a diagnosis of dementia did not have an annual medical assessment, nor a current reappraisal, which poses a potential health and safety risk to persons in care.
	POC Due Date: 09/24/2024
	Plan of Correction
1 2 3 4	Administrator agreed to contact resident's physician and obtain a new medical assessment and to complete a reappraisal for the resident. Proof of new physician's report and reappraisal to be submitted to CCL by POC due date.

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: Kristin Heffernan	TELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Kelly Dulek	TELEPHONE: (951) 836-3170
LICENSING EVALUATOR SIGNATURE:	DATE: 09/10/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/10/2024

LIC809 (FAS) - (06/04)

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