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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850312
Report Date: 10/18/2025
Date Signed: 10/30/2025 04:13:15 PM

Document Has Been Signed on 10/30/2025 04:13 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:OMNICARE IIFACILITY NUMBER:
565850312
ADMINISTRATOR/
DIRECTOR:		KULUNGU, LAILA LANDUFACILITY TYPE:
740
ADDRESS:154 THAMES STTELEPHONE:
(818) 274-1809
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 4DATE:
10/18/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:34 AM
MET WITH:Ann Jaimes, StaffTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a required annual inspection. LPA was greeted by staff and informed them of the reason for the visit. Administrator Laila Kulungu was called and reason for the visit was explained.

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: 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. Full rail observed on resident #1's (R1) bed. R1 is not on hospice. 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 106.9 – 111.7 degrees Fahrenheit, which is within the required range. COMMON AREAS: Common areas were appropriately furnished and in good condition. The facility smoke alarm system is hard wired; smoke detectors were tested and were operable at the time of the visit. (Continue to LIC809c)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2025
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 5
California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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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: OMNICARE II
FACILITY NUMBER: 565850312
VISIT DATE: 10/18/2025
NARRATIVE
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Fire extinguisher located in the kitchen was observed fully charge with receipt dated 10/16/2024. Administrator stated she will have a new fire extinguisher at the facility by Monday, 10/20/2025. 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.

RECORD REVIEW: Records review began at 12PM-1:30PM. 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. Personnel files reviewed were in order and had no missing documents. At 12:30PM, LPA observed three (3) out of four (4) resident files to be missing a PRN Authorization letter from the physician for resident #2, #3 and resident #4.

MEDICATIONS: Medications are stored inaccessible in locked cabinets in the kitchen and office area. Beginning at 2PM, 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.

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.

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.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/30/2025 04:13 PM - It Cannot Be Edited


Created By: Zabel Chochian On 10/18/2025 at 03:37 PM
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: 10/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(5)(B)
Postural Supports
(B) Bed rails that extend the entire length of the bed are prohibited except for residents who are currently receiving hospice care and have a hospice care plan that specifies the need for full bed rails.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Full rail observed on R1's bed. R1 is not on hospice. This poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/18/2025
Plan of Correction
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Staff removed full rail during todays visit. Administrator stated she will communicate with the family and R1's physician to obtain a half rail order.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Zabel Chochian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 10/30/2025 04:13 PM - It Cannot Be Edited


Created By: Zabel Chochian On 10/18/2025 at 03:37 PM
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: 10/18/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(d)
Incidental Medical and Dental Care Services
(d) If the resident is unable to determine his/her own need for a prescription or nonprescription PRN medication, and is unable to communicate his/her symptoms clearly, facility staff designated by the licensee, shall be permitted to assist the resident with self-administration, provided all of the following requirements are met:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review, the licensee did not comply with the section cited above in three out of four resident records reviewed, licensee did not have PRN authorization letters from the physician for residents #2,#3 and #4 (PRN medication observed on hand for these residents). This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/24/2025
Plan of Correction
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Administrator stated that she will obtain the PRN authorization letters from the physician.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Zabel Chochian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/18/2025


LIC809 (FAS) - (06/04)
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