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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850312
Report Date: 10/18/2023
Date Signed: 10/18/2023 11:37:04 AM


Document Has Been Signed on 10/18/2023 11:37 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:OMNICARE IIFACILITY NUMBER:
565850312
ADMINISTRATOR:KULUNGU, LAILA LANDUFACILITY TYPE:
740
ADDRESS:154 THAMES STTELEPHONE:
(818) 274-1809
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY:6CENSUS: 5DATE:
10/18/2023
TYPE OF VISIT:PrelicensingUNANNOUNCEDTIME BEGAN:
09:40 AM
MET WITH:Laila KulunguTIME COMPLETED:
11:45 AM
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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility announced at 9:40 a.m. to conduct a
pre-licensing inspection. This is a change of ownership application from Omnicare II (#565801460) to Omnicare II (#565850312). The LPA met with Administrator Laila Kulungu. All rooms are cleared for non-ambulatory residents. The fire clearance was granted on 5/3/2023; in which bedridden residents are permitted in Bedroom #3. Component III was waived as the applicant currently operates two other Residential Care Facilities for the Elderly (RCFE)’s that are currently in good standing. Component III was successfully completed on 8/28/2023.

At 9:55 a.m., the LPA toured the physical plant areas inside and outside with the applicant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen knives are stored locked and inaccessible in a drawer in the kitchen. The supply of nonperishable food is adequate. The supply of dishes is adequate. Appliances in the kitchen were clean and functional. There is an adequate supply of emergency food. Medications are stored in a locked kitchen cabinet and files are stored in a locked filing cabinet in the office area next to the kitchen.


BEDROOMS: There are (6) six bedrooms in the facility; all bedrooms for resident use are private. There is no staff room in the facility as there is no live in staff. Three (3) of six (6) rooms have direct access to the outside. Lighting in the rooms is adequate. All resident rooms were set up with beds, night stands, lighting, chests of drawers, chairs and closet space.
BATHROOMS: There are (3) full bathrooms. There are (2) private bathrooms for resident use and (1) hallway bathroom for resident use. The showers are equipped with nonskid surfaces and available nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between 108.6-115.8 degrees Fahrenheit.

Continued on LIC 809-C
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:
DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2023
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 2


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: OMNICARE II
FACILITY NUMBER: 565850312
VISIT DATE: 10/18/2023
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COMMON AREA: The common areas were appropriately furnished, and the lighting was adequate. There is a television and other entertainment equipment in the living room area. There is a covered fireplace. The facility smoke alarm system is hard wired; the smoke detectors were operable at the time of the visit. There is (1) fire extinguisher which was fully charged and last purchased on 8/31/2023. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted in the main hallway area wall. Other required postings are also posted on the main hallway area wall.
MEDICATIONS: Medications are in a locked medication cabinet in the kitchen. The first aid supplies were complete, including a first aid manual.
FILES: Resident and staff records are stored in a locked filing cabinet in the office area next to the kitchen.
LAUNDRY: The laundry area is in the attached garage. Laundry detergent and chemicals are stored inaccessible in the garage.
EXTERIOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio area with tables and chairs for resident use located directly outside the sliding doors from the living room. There is a gated and locked pool in the backyard. The facility has a self-latching exit gate located on both side passageways. There is no front yard gate or driveway gate. The garage is attached to the property and is used for additional storage, emergency supplies, additional food and laundry.
INFECTION CONTROL: The facility has a central entry point for symptom screening and sanitation station for staff, residents, and visitors. The facility has 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.

Facility is in compliance with Title 22 Regulations at this time. 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 license number until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license.

Exit interview conducted and report issued.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Elsie CamposTELEPHONE: (747) 230-3909
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2023
LIC809 (FAS) - (06/04)
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