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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850311
Report Date: 11/01/2023
Date Signed: 11/02/2023 09:50:27 AM

Document Has Been Signed on 11/02/2023 09:50 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:OMNICARE IIIFACILITY NUMBER:
565850311
ADMINISTRATOR:KULUNGU, LAILA LANDUFACILITY TYPE:
740
ADDRESS:1446 SUFFOLK AVENUETELEPHONE:
(818) 274-1809
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 6DATE:
11/01/2023
TYPE OF VISIT:PrelicensingANNOUNCEDTIME BEGAN:
10:25 AM
MET WITH:Laila Landu KulunguTIME COMPLETED:
03:16 PM
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Licensing Program Analyst (LPA) Sandra Urena conducted a pre-licensing visit to the above noted facility. The LPA met with Administrator, Laila Kulungu. This is an application for a Change of Ownership (CHOW). The facility applied for five (5) non-ambulatory residents, and one (1) bedridden resident.

At 10:40 a.m., the LPA and the facility designee conducted a physical plant tour inside and out to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The facility is a one story dwelling. An approved fire clearance was received on 10/23/2023, clearing them for five (5) non-ambulatory residents; one (1) bedridden resident in bedroom #2.

KITCHEN: Kitchen knives are stored in a locked kitchen drawer. The supply of dishes, utensils, pots, pans, and drink ware is adequate. The temperatures for the refrigerator and freezer could not be verified as neither have a thermometer. The supply of nonperishable food is adequate. There are no pesticides (poisons) or toxins stored in any food storage area or preparation area with utensils. Appliances in the kitchen were clean and all appeared functional. Trash cans had tight fitting lids. Kitchen, and house cleaning supplies are stored and locked under the sink cabinet area. No flies or other vermin were observed. Water temperature was recorded at 112.3 degrees Fahrenheit.

BEDROOMS: The facility has six (6) private residents’ bedrooms, and one (1) staff’s bedroom, total of seven(7) bedrooms. Bedroom # 2 has been approved and cleared for one bedridden resident. All bedrooms were set up with night stands, lamps, and closet space. The screen sliding door in bedroom#2 became jammed when trying to slide it open.

Continues on LIC 809C...
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/01/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OMNICARE III
FACILITY NUMBER: 565850311
VISIT DATE: 11/01/2023
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All beds were furnished with box springs, comfortable mattress and clean linen, which includes, a mattress pad, top and bottom linens, pillowcases, and a bedspread. Lighting in the rooms appeared adequate. The bedrooms were large enough to allow for easy passage between the beds and furniture with a wheelchair or walker. All rooms were free of odors. All window screens were clean and maintained in good repair.

BATHROOMS: There are three (3) bathrooms. One is a private bathroom located in bedroom #1. Two (2) bathrooms are located in the hallways and are for residents' and staff use. Hot water temperature was tested in all restrooms and recorded between 110.3- and 116.5-degrees Fahrenheit.

COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. There are televisions and other entertainment equipment, books and/or activity supplies in the family room. There was sufficient space to accommodate both indoor and outdoor activities. There is a fireplace in the living room, which is missing a fireplace cover. Alarms on all exterior doors were engaged at the time of visit and functional. In addition, the physical plant is consistent with the submitted facility sketch/floor plan. The facility had emergency lighting, which included flashlights, or other battery powered lighting, and batteries. The facility recorded a comfortable temperature of 73 degrees Fahrenheit.

The facility smoke alarm system is hard wired. The smoke detectors were tested and functioned properly during the time of visit. There is one (1) fire extinguisher mounted on the wall. The extinguisher was last serviced on 08/03/2023. There is a functioning telephone on the premises. The emergency exiting plans/sketch are posted on the wall by bedroom #6, as well as other required postings. Resident and staff records are stored in a filing cabinet, which is currently located in the office area.

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SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OMNICARE III
FACILITY NUMBER: 565850311
VISIT DATE: 11/01/2023
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Medications are centrally stored in a locked top cabinet located in the office area. The first aid kit was available but is missing the manual. The laundry room is located in the hallway adjacent to the family room. Laundry supplies and chemicals are stored in locked cabinets, inaccessible to residents in care. Garage was observed locked and contained extra food, PPE supplies, cleaning supplies, and emergency food and water supply.

OUTDOOR/GARAGE AREA: The exterior passageways were clean and clear of any obstructions. There is a covered patio and patio furniture. Three recliners ready to be disposed of, need to be removed from patio area. The entire property is fenced. The back and sides of the house are separated from the front yard by gates at the north and south side passageways.

The following deficiencies were observed during the inspection and the applicant agree to have them resolved by Monday, November 6, 2023.

1. Bedrooms: The screened sliding door in bedroom#2 became jammed when trying to slide it open.
2. Living Room: The fireplace in the living room, is missing a fireplace cover.
3. Kitchen: Refrigerator and freezer need a thermometer.
4. Outdoor: Three recliners ready to be disposed of, need to be removed from patio area.
5. Miscellaneous: First Aid kit is missing the first aid manual.
6. Seven (7) day supply of food and water need expiration dates.

At 1:25 p.m., the applicant/Administrator completed Component III Orientation.

This report will be sent to the Centralized Application Bureau (CAB). You will be notified by the CAB Analyst when your license has been approved. You are not allowed to begin operating until you have been notified that your license has been approved by the CAB Analyst. Failure to comply could affect approval of your license.

Exit interview was conducted and reviewed with Administrator Laila Kulungu. A copy of the report was issued.
SUPERVISORS NAME: Kasandra Lopez
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 11/01/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/01/2023
LIC809 (FAS) - (06/04)
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