<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


COMPLAINT INVESTIGATION REPORT

Facility Number: 567609831
Report Date: 09/24/2026
Date Signed: 09/24/2026 01:59:18 PM

Substantiated


STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2026 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20260609111158
FACILITY NAME:ROYAL OAKS INNFACILITY NUMBER:
567609831
ADMINISTRATOR:JAKOBOVICH, BRANDONFACILITY TYPE:
740
ADDRESS:45 ERBES RDTELEPHONE:
(805) 495-4657
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY:80CENSUS: 36DATE:
09/24/2026
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Brandon JakobovichTIME COMPLETED:
02:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Medications are not administered as prescribed
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint visit with the purpose of delivering findings for the allegation listed above. Upon arrival, LPA met with Administrator Brandon Jakobovich. Entrance interview conducted.

During an initial visit conducted on 06/17/2026, LPA conducted interviews with three (3) staff members between 10:29AM-11:20AM, toured the facility with Facility Designee at 11:21AM, reviewed medications for Resident #1 (R1) at 11:28AM and reviewed and obtained copies of documents relevant to the investigation. During the facility tour at 11:25AM, LPA observed and briefly spoke with R1. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with relevant parties. The following was then determined:

Report Continued on LIC 9099-C

Substantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 1 of 5
Control Number 29-AS-20260609111158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROYAL OAKS INN
FACILITY NUMBER: 567609831
VISIT DATE: 09/24/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation “Medications are not administered as prescribed:”
The complaint alleges that R1’s medications that were prescribed for a scabies diagnosis were not administered as prescribed. LPA reviewed Medication Administration Record (MAR) and prescription orders for R1 during the initial visit. The dermatologist R1 visited on 05/05/2026 prescribed Ivermectin 3mg tablet with the following instructions: “take 3 tablets on day 0, day 1, day 7, day 8 and day 15.” The MAR provided to the LPA shows the medication was administered on the following dates: 05/07/2026, 05/08/2026, 05/13/2026, 05/14/2026, and 05/21/2026. On the MAR, instructions indicate “take 3 tablets (=9mg) by mouth once daily on day 1, 2, 7, 8, 15. Interview revealed R1’s hospice nurse marked the specific dates on a calendar that was in the medication room, which correspond with the schedule on the MAR, not the day indicators on the written prescription. Additionally, R1’s family member provided the LPA with a MAR that the facility printed on 06/02/2026. This printed MAR indicates R1’s Ivermectin was administered daily from 05/08/2026 through 05/18/2026 and 05/20/2026 through 05/22/2026. It is unclear which MAR reflects the actual administration of this medication, however, neither MAR reflects an accurate administration that matches the prescription orders. Further, no documentation was provided indicating the facility contacted R1’s prescribing doctor to obtain clarification on the discrepancy observed between the prescription and the MAR for R1’s Ivermectin. The complainant also alleged R1’s permethrin cream was not administered properly, as it was discontinued prior to the date indicated on the prescription orders. LPA observed Permethrin 5% topical cream was prescribed with the following instructions: “apply topically from neck down nightly for one week, then twice weekly until resolved.” MAR indicates the cream was applied daily from 05/08/2026 through 05/12/2026. In R1’s file, there was a document entitled physician order which was signed by RNCM for R1’s hospice provider. This order stated “please discontinue: permethrin cream.” No further instruction was provided and this order was not signed by a physician, however, the MAR indicates the cream was discontinued at 10:00AM on 05/13/2026. No documentation was provided signed by the prescribing doctor or any other communication with the prescribing provider indicating the medication should be discontinued. It should also be noted that start dates for both medications mentioned in this section reflect a start date of 05/10/2026, which contradicts the documentation in the MAR. Based on information gathered during the course of the investigation, there is sufficient evidence to support the allegation; therefore, the allegation is deemed SUBSTANTIATED at this time.
Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiency was cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiency may result in civil penalties. Exit interview conducted, appeal rights discussed and a copy of this report and appeal rights were provided.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC9099 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
This is an official report of an unannounced visit/investigation of a complaint received in our office on
06/09/2026 and conducted by Evaluator Kelly Dulek
COMPLAINT CONTROL NUMBER: 29-AS-20260609111158

FACILITY NAME:ROYAL OAKS INNFACILITY NUMBER:
567609831
ADMINISTRATOR:JAKOBOVICH, BRANDONFACILITY TYPE:
740
ADDRESS:45 ERBES RDTELEPHONE:
(805) 495-4657
CITY:THOUSAND OAKSSTATE:CAZIP CODE:
91362
CAPACITY:80CENSUS: 36DATE:
09/24/2026
UNANNOUNCEDTIME BEGAN:
12:15 PM
MET WITH:Brandon JakobovichTIME COMPLETED:
02:10 PM
ALLEGATION(S):
1
2
3
4
5
6
7
8
9
Facility failed to communicate with resident's responsible party
INVESTIGATION FINDINGS:
1
2
3
4
5
6
7
8
9
10
11
12
13
Licensing Program Analyst (LPA) Kelly Dulek arrived at the facility unannounced to conduct a subsequent complaint visit with the purpose of delivering findings for the allegation listed above. Upon arrival, LPA met with Administrator Brandon Jakobovich. Entrance interview conducted.

During an initial visit conducted on 06/17/2026, LPA conducted interviews with three (3) staff members between 10:29AM-11:20AM, toured the facility with Facility Designee at 11:21AM, reviewed medications for Resident #1 (R1) at 11:28AM and reviewed and obtained copies of documents relevant to the investigation. During the facility tour at 11:25AM, LPA observed and briefly spoke with R1. Throughout the course of the investigation, LPA reviewed all documents obtained and conducted telephonic interviews with relevant parties. The following was then determined:

Report Continued on LIC 9099-C
Unsubstantiated
Estimated Days of Completion:
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC9099 (FAS) - (06/04)
Page: 3 of 5
Control Number 29-AS-20260609111158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROYAL OAKS INN
FACILITY NUMBER: 567609831
VISIT DATE: 09/24/2026
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
Allegation “Facility failed to communicate with resident’s responsible party:”

It was alleged that facility staff did not communicate with R1’s family regarding the resident’s scabies diagnosis timely. Documents reviewed for R1’s dermatologist visit on 05/05/2026 indicates a diagnosis of scabies “proven through KOH prep.” Document indicated R1’s family member was present during the visit and “understands plan.” R1 returned to the facility following their 05/05/2026 appointment. Interview revealed R1 had a follow up appointment with the dermatologist on 05/14/2026. R1's family member accompanied R1 to this appointment. Interview with staff revealed the paperwork from R1’s dermatologist appointment was provided via hand delivery by R1’s family member on 05/14/2026 at 05:38PM. The document included information of R1's diagnosis and treatment plan and confirmed R1's family member was aware of the diagnosis at that time. Facility designee acknowledged receiving the paperwork documenting R1’s positive diagnosis on 05/14/2026 and notification was sent to all facility responsible parties via email on 05/18/2026 at 10:08AM. The information obtained during the investigation did not include sufficient evidence to corroborate the allegation. Although the allegation may have happened or is valid, there is not sufficient evidence to prove the alleged violation did or did not occur, therefore the allegation is deemed Unsubstantiated at this time.

No citations issued related to the above allegation. Exit interview conducted. A copy of today's report was provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC9099 (FAS) - (06/04)
Page: 4 of 5
Control Number 29-AS-20260609111158
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: ROYAL OAKS INN
FACILITY NUMBER: 567609831
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/24/2026
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
10/08/2026
Section Cited
CCR
87465(a)(4)
1
2
3
4
5
6
7
87465(a) (4) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
1
2
3
4
5
6
7
Administrator agreed to provide documentation training to all staff handling medications and will submit proof of training to CCL by POC due date.
8
9
10
11
12
13
14
Based on interview and record review, the licensee did not comply with the above cited section, as R1’s prescription Ivermectin was not documented as administered on the dates it was prescribed, which posed a potential health risk to persons in care.
8
9
10
11
12
13
14
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
1
2
3
4
5
6
7
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: Kelly Dulek
LICENSING EVALUATOR SIGNATURE:

DATE: 09/24/2026
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/24/2026
LIC9099 (FAS) - (06/04)
Page: 5 of 5