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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609762
Report Date: 07/25/2022
Date Signed: 07/25/2022 12:34:16 PM

Document Has Been Signed on 07/25/2022 12:34 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:ENDURING OAKS ASSISTED LIVING THOUSAND OAKSFACILITY NUMBER:
567609762
ADMINISTRATOR:YACOUB, MIRVATFACILITY TYPE:
740
ADDRESS:952 E JANSS RDTELEPHONE:
(805) 852-5130
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
07/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Mirvat YacoubTIME COMPLETED:
12:35 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 10:45 a.m. The last annual conducted at this facility was on 6/21/2021. This annual has a specific emphasis on infection control practices and procedures. The LPA was greeted and scanned at the door by Staff, Al. The Administrator, Mirvat arrived shortly after and was explained the reason for the visit. Entrance interview.

At 11:25 a.m., the LPA began the physical plant tour of the common areas, kitchen area, resident bedrooms, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. The LPA observed knives and sharps in a drawer next to the oven locked and inaccessible to residents. Cleaning supplies and toxins were observed locked in a cabinet under the sink at the time of visit. Fire extinguishers were observed and last serviced on April 2022.

BEDROOMS: The LPA observed the resident rooms, which were furnished appropriately with clean linens, furnishings, and sufficient lighting.

RESTROOMS: There are five (5) resident restrooms, one in each resident bedroom. Resident bathrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Restrooms are sufficiently stocked with hand liquid soap and paper towels. Bathrooms were measured for hot water, temperatures measured between 105.8- and 140.2-degrees Fahrenheit. The Administrator adjusted water temperature at the time of visit.

…Continued on LIC 809C…

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/25/2022
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: ENDURING OAKS ASSISTED LIVING THOUSAND OAKS
FACILITY NUMBER: 567609762
VISIT DATE: 07/25/2022
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...Continued from LIC 809...

GARAGE AND GROUNDS: The garage is attached to the house and locked at all times. Cleaning supplies and chemicals are stored and inaccessible to residents in the laundry room. There is one (1) additional refrigerator in the garage with perishable items in good condition. There is a covered patio area with patio furniture including a table and chairs for resident use. Facility has two (2) fence gates that self-latch with clear passageways for emergency exit use. No large bodies of water accessible to residents at the time of visit.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating, a table, and television for resident use. The LPA observed Medications locked in cabinets in the dining room at the time of visit. At 11:25 a.m., the LPA observed three (3) residents watching television in the living room.

During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, and symptoms of COVID-19. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. Staff were observed wearing face coverings at the time of visit. If needed, the facility has the capacity to self isolate residents if the facility has a confirmed case of COVID-19.

The LPA and Administrator discussed staff vaccination requirements. All staff are fully vaccinated. No identified staffing concerns. The facility is in compliance regarding the requirements for indoor and outdoor visitation. The facility’s policies and procedures as it pertains to infection control are adequate.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Appeal Rights Discussed. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:

DATE: 07/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/25/2022 12:34 PM - It Cannot Be Edited


Created By: Martha Arroyo On 07/25/2022 at 12:05 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: ENDURING OAKS ASSISTED LIVING THOUSAND OAKS
FACILITY NUMBER: 567609762

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/25/2022

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA’s observation, the licensee did not comply with the section cited above as the resident bathroom faucets deliver hot water measured between 105.8- and 140.2-degrees Fahrenheit, which poses an immediate health and safety risk to persons in care.
POC Due Date: 08/01/2022
Plan of Correction
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The Administrator adjusted the thermostat during time of visit and has agreed to submit a hot water temperature log for five (5) days to show that the hot water is being maintained between temperatures 105- and 120-degrees Fahrenheit to CCL by 8/01/2022.
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.
SUPERVISOR'S NAME:Desaree Perera
LICENSING EVALUATOR NAME:Martha Arroyo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/25/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/25/2022


LIC809 (FAS) - (06/04)
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