565850291-12-21-2022-29-AS-TCAA-CMBRRM-20221221121523

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850291
Report Date: 12/21/2022
Date Signed: 12/21/2022 12:16:24 PM

Document Has Been Signed on 12/21/2022 12:16 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:	OAKMONT OF SIMI VALLEY		FACILITY NUMBER:	565850291
ADMINISTRATOR:	SIDNEY, KEVAN		FACILITY TYPE:	740
ADDRESS:	3110 ROYAL AVE		TELEPHONE:	(949) 744-5200
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	121	CENSUS: 71	DATE:	12/21/2022
TYPE OF VISIT:	Prelicensing	UNANNOUNCED	TIME BEGAN:	10:19 AM
MET WITH:	Vivian Reyes		TIME COMPLETED:	12:30 PM

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) Teresa Camara arrived at the facility at 10:19 a.m. for an announced change of ownership pre-licensing inspection. Upon arrival, the LPA met with Health Services Director Vivian Reyes. Executive Director Kevan Sidney was unable to attend the meeting. The applicants successfully completed Component II on 11/30/2022 and Component III on 12/20/2022. All rooms have a fire clearance for non-ambulatory and bedridden use; however, this facility shall be limited to a maximum capacity of eight (8) bedridden residents. This facility has an approved Hospice Waiver for eight (8) residents. COMMON AREAS: The physical plant tour took place at 10:22 a.m. - 11:44 a.m. The facility is a two-story building with two working elevators and three stairwells. On the first floor there are kitchen facilities, dining room, bistro, laundry rooms, medication room, bar/lounge, library, activity rooms, formal sitting areas, beauty salon, fitness center, wellness center, offices, and common restrooms. On the second floor there is a media room, laundry rooms, and common restrooms. The LPA observed fireplaces in the first-floor dining area, library/reading room, the Bistro, and the formal sitting room. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. The facility uses a signal system, which is activated via pull cord in assisted living resident units and common areas. Alerts are sent to the front desk and pagers carried by staff. Residents also have the option to use a pendant. Wanderguard is also offered to residents as needed. The paging system was tested randomly throughout the visit and it was in operating condition. Memory care residents have motion sensors in their room in lieu of pull cords or pendants. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted throughout the facility. Other required postings were posted in the large activity room on the first floor. CONT 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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: OAKMONT OF SIMI VALLEY	FACILITY NUMBER: 565850291
	VISIT DATE: 12/21/2022

NARRATIVE

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There are fire extinguishers throughout the facility, which were serviced 7/11/2022. The building fire suppression system, smoke detectors and carbon monoxide detectors were last inspected by Cal Building Systems on 7/12/2022 for an annual inspection and they also performed a maintenance inspection 11/17/2022. All systems were observed to be in operating condition. The LPA obtained appropriate documentation regarding the fire inspection for the hard file.

The LPA toured the outside area of the facility. There are four outdoor gated courtyards: one is designated for Memory Care residents and the other three are designated for Assisted Living residents, including a small fenced dog park. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Facility has a 20-seat passenger bus and a car for transportation needs. There is parking available for resident use, including 8 garage spaces.

MEDICATION: There were two medication rooms on the first floor; one is designated for Assisted Living residents and the other for Memory Care residents. There were several complete first-aid kits and a surplus of medical supplies. The medication carts are equipped with a double locking system for narcotics.

KITCHEN: The main kitchen and dining room are located on the 1st floor. Food is prepared in the main kitchen and delivered to the dining area and the Memory Care dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Fresh food was properly stored and in sufficient quantities. There was an emergency 7-day supply of food and water in separate storage areas.

RESIDENT ROOMS: Memory Care is located on the first floor and has 29 rooms. Out of the 29 rooms, 5 are identified for double occupancy. The Memory Care Unit has studio apartments with no appliances. There is a separate dining space for Memory Care residents, and food is prepared in the main kitchen and brought into the dining space for meals. All rooms in the Memory Care Unit are complete with properly installed grab-bars in resident bathrooms and non-skid surfaces in shower tubs. There are motion sensors installed in all Memory Care units. Delayed egress was tested in the Memory Care unit and it was operational at the time of the visit.

CONT 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

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: OAKMONT OF SIMI VALLEY	FACILITY NUMBER: 565850291
	VISIT DATE: 12/21/2022

NARRATIVE

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RESIDENT ROOMS (cont): There are 52 Assisted Living units which are located on both the first and second floor of the building. Assisted Living units are either studio, one, or two bedroom units and rooms are equipped with a refrigerator, sink, and microwave. Some rooms also have stove tops. All rooms in the Assisted Living Unit have properly installed grab-bars in resident bathrooms and non-skid surfaces in shower tubs.

During today's visit, water temperature was tested throughout the units and temperature ranged between 107.1 to 116.1 degrees Fahrenheit, which is within the required range per regulation of 105 to 120 degrees Fahrenheit.

The physical plant is in compliance with Title 22 regulations. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate under the new facility number until they have been notified that the change of ownership license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 12/21/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/21/2022

LIC809 (FAS) - (06/04)

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