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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609831
Report Date: 12/09/2024
Date Signed: 12/09/2024 02:44:00 PM

Document Has Been Signed on 12/09/2024 02:44 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:ROYAL OAKS INNFACILITY NUMBER:
567609831
ADMINISTRATOR/
DIRECTOR:		JAKOBOVICH, BRANDONFACILITY TYPE:
740
ADDRESS:45 ERBES RDTELEPHONE:
(805) 495-4657
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY: 80CENSUS: 51DATE:
12/09/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:14 AM
MET WITH:Brandon JakobovichTIME VISIT/
INSPECTION COMPLETED:
02:50 PM
NARRATIVE
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Licensing Program Analyst (LPA) Angela Barutyan conducted a Case Management - Deficiencies visit in conjunction with a complaint visit (Complaint Control # 29-AS-20241206113504). The purpose of the visit is to issue a citation for deficiencies observed during the initial complaint investigation.

During the visit on 12/09/2024 between 10:30AM – 11:20AM, LPA reviewed four (4) resident files and observed Resident #1 (R1) and Resident #2 (R2) with a dementia diagnosis without a current physician’s report for 2024 (both dated 08/17/2022). Administrator Holly Gold stated that the residents are seen by hospice nurses and doctors and that the forms have been sent to the doctor to be filled out. However, Administrator was unable to provide physician’s reports for 2023.

R1 and R2 also did not have current appraisals of needs and services with R1’s dated 03/19/2021 and R2’s dated 09/03/2021. Administrator stated that they have R1’s current appraisal and provided LPA with an unsigned copy dated on 03/21/2024. Administrator signed the copy today, 12/09/2024, with the date 03/21/2024, but resident or responsible party of resident remained unsigned at the time of the visit. Administrator stated that the appraisal has been reviewed with R1’s family.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22. Administrator was informed that failure to correct deficiency may result in civil penalties.

Exit interview was conducted. A copy of the report and appeal rights were provided.

SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Angela Barutyan
LICENSING EVALUATOR SIGNATURE: DATE: 12/09/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/09/2024
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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Document Has Been Signed on 12/09/2024 02:44 PM - It Cannot Be Edited


Created By: Angela Barutyan On 12/09/2024 at 01:30 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: ROYAL OAKS INN
FACILITY NUMBER: 567609831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/09/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
12/23/2024
Section Cited
CCR
87705(c)(5)

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87705 Care of Persons with Dementia (c) Licensees who accept...residents with dementia shall be...ensuring the following: (5) Each resident with dementia shall have an annual medical assessment...and a reappraisal done at least annually... This requirement was not met as evidenced by:
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Licensee and Administrator stated they will obtain current medical assessments and reappraisals for R1 and R2 and submit proof to CCL by 12/23/2024.
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Based on record review, the licensee did not comply with the section cited above as R1 and R2 have dementia and did not have an annual medical assessment and reappraisal which poses a potential health, safety, or personal rights risk to persons in care.
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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:Kristin Heffernan
LICENSING EVALUATOR NAME:Angela Barutyan
LICENSING EVALUATOR SIGNATURE:
DATE: 12/09/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/09/2024


LIC809 (FAS) - (06/04)
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