565850312-10-24-2024-29-AS-ABAN-DACQHX-20241024121153

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565850312
Report Date: 10/24/2024
Date Signed: 10/24/2024 12:12:13 PM

Document Has Been Signed on 10/24/2024 12:12 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	OMNICARE II		FACILITY NUMBER:	565850312
ADMINISTRATOR/ DIRECTOR:	KULUNGU, LAILA LANDU		FACILITY TYPE:	740
ADDRESS:	154 THAMES ST		TELEPHONE:	(818) 274-1809
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 4	DATE:	10/24/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:40 AM
MET WITH:	Laila Kulungu		TIME VISIT/ INSPECTION COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual inspection at 09:40AM. LPA was greeted by staff and informed them of the reason for the visit. Administrator Laila Kulungu arrived at 10:36AM.

The LPA and the 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. The following was observed:

KITCHEN: LPA toured the kitchen at 09:45AM. Kitchen knives are stored locked and inaccessible in a drawer in the kitchen. The facility has a sufficient supply of perishable and non-perishable food. Appliances in the kitchen were clean and functional. There is an adequate supply of emergency food and water. 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.

GARAGE/LAUNDRY: The attached garage by the kitchen is kept locked. LPA observed the pantry, an additional refrigerator/freezer, and a washer and dryer. Laundry detergent and chemicals are stored inaccessible in the garage.

BEDROOMS: There are six (6) 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.

Report continued on LIC-809C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OMNICARE II	FACILITY NUMBER: 565850312
	VISIT DATE: 10/24/2024

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BATHROOMS: There are three (3) full bathrooms. There are two (2) private bathrooms for resident use and one (1) hallway bathroom for resident use. The showers are equipped with nonskid surfaces and nonskid mats. Grab bars were observed in the bathrooms. Hot water temperature in bathrooms measured between 108.5 – 114.5 degrees Fahrenheit, which is within the required range.

COMMON AREAS: These include the office area, dining area, and living room. Common areas were appropriately furnished and in good condition. The facility smoke alarm system is hard wired; smoke detectors were tested at 10:06AM and were operable at the time of the visit. There is one (1) fire extinguisher which was fully charged and last purchased on 10/16/2024. 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.

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. The garage is attached to the property and is used for additional storage, emergency supplies, additional food and laundry.

MEDICATIONS: Medications are stored inaccessible in locked cabinets in the kitchen and office area. Beginning at 10:11AM, LPA observed medications for two (2) residents. Medications were observed to be properly documented on the centrally stored medications and destruction record and were in compliance with regulation, state, and federal law.

RECORD REVIEW: Records review began at 10:29AM. LPA observed all four (4) resident records for documents including, but not limited to: needs and service appraisals, medical records, admissions agreement, and consent forms. LPA observed three (3) personnel records for documents including, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All resident files were in order and had no missing documents. At 10:57AM, LPA observed two (2) out of three (3) personnel files to be missing 20 hours annual training.

Report continued on LIC-809C.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 10/24/2024 12:12 PM - It Cannot Be Edited

Created By: Angela Barutyan On 10/24/2024 at 11:52 AM

Link to Parent Document Below:

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: OMNICARE II	FACILITY NUMBER: 565850312
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/24/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

HSC

1569.625(b)(2)

Other Provisions

(2) In addition to paragraph (1), training requirements shall also include an additional 20 hours annually, eight hours of which shall be dementia care training, as required by subdivision (a) of Section 1569.626, and four hours of which shall be specific to postural supports, restricted health conditions, and hospice care, as required by subdivision (a) of Section 1569.696. This training shall be administered on the job, or in a classroom setting, or both, and may include online training. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on interviews and record review, the licensee did not comply with the section cited above as 2 out of 3 staff did not have 20 hours of annual training which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 11/07/2024
	Plan of Correction
1 2 3 4	Administrator agreed to have staff complete training and send proof to CCL by 11/07/2024.

Type B

Section Cited

HSC

1569.695(c)

Other Provisions

(c) A facility shall conduct a drill at least quarterly for each shift. The type of emergency covered in a drill shall vary from quarter to quarter, taking into account different emergency scenarios. An actual evacuation of residents is not required during a drill. While a facility may provide an opportunity for residents to participate in a drill, it shall not require any resident participation. Documentation of the drills shall include the date, the type of emergency covered by the drill, and the names of staff participating in the drill. 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 as emergency drills were not being conducted quartly which posed a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 10/31/2024
	Plan of Correction
1 2 3 4	Staff conducted an emergency drill during the visit. POC is cleared.

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

LICENSING EVALUATOR NAME:

Angela Barutyan

LICENSING EVALUATOR SIGNATURE:

DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

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 II	FACILITY NUMBER: 565850312
	VISIT DATE: 10/24/2024

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INFECTION CONTROL: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are not conducted quarterly as is required. Staff conducted a fire drill during the visit.

INTERVIEWS: During today’s visit, LPA interviewed two (2) residents and three (3) staff.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE:	DATE: 10/24/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/24/2024

LIC809 (FAS) - (06/04)

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