567609831-9-13-2021-29-AS-SWAR-C6TT6K-20210913142715

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609831
Report Date: 09/13/2021
Date Signed: 09/13/2021 02:28:44 PM

Document Has Been Signed on 09/13/2021 02:28 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:	ROYAL OAKS INN		FACILITY NUMBER:	567609831
ADMINISTRATOR:	JAKOBOVICH, BRANDON		FACILITY TYPE:	740
ADDRESS:	45 ERBES RD		TELEPHONE:	(805) 495-4657
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91362
CAPACITY: 80		CENSUS: 56	DATE:	09/13/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:47 AM
MET WITH:	Holly Gold, Administrator		TIME COMPLETED:	02:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Salia Walker arrived at the facility unannounced to conduct a required Annual visit at 10:47 a.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Holly Gold at 10:50 a.m. and explained the reason for the visit.

The LPA toured the physical plant areas inside and outside, with Administrators Holly Gold, and Ashley Jackson at 10:57 a.m., to ensure there are no health and safety hazards.
Kitchen: The kitchen area appeared clean and sanitary. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Food in the refrigerator/freezer were properly labeled. All knives and cleaning supplies were observed to be properly stored and locked at time of visit. Hot water measured 105.8 Fahrenheit at 11:06 a.m.
Bedrooms: The LPA observed resident bedrooms which were furnished with clean linens, appropriate furnishings, and sufficient lighting.
Restrooms: Each bathroom is designed as a ½ bathroom; the facility has designated shower rooms throughout the facility. The resident bathrooms and shower rooms are properly equipped with grab bars and shower rooms are equipped with non-skid material. Hot water was randomly tested throughout the facility inspection; temperature ranged between 105.3-114.2 degrees Fahrenheit.
Common Areas: Fire extinguishers were observed throughout the facility, and were fully charged. The building is a one-level facility, which consists of offices, activity rooms, medication room, laundry room, multiple supply closets, beauty parlor, staff room, kitchen/dining room, and multiple shower rooms. The LPA observed common areas, including furniture and activity equipment, to be clean and in good condition. A separate Food Storage room contains additional nonperishable, and perishable food items. At 10:59 a.m. and 11:00 a.m., the LPA observed two (2) unlocked storage rooms with accessible housed hazardous materials. The Administrator secured both storage rooms at the time of observation.

Continued on LIC 809C..

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

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: ROYAL OAKS INN	FACILITY NUMBER: 567609831
	VISIT DATE: 09/13/2021

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Surrounding Grounds: Entry/exits were free of obstruction. Medication room: First aid kit, medications, and medication records are kept in the medication room. The First Aid Kit was complete with a thermometer, scissor, tweezers, bandage and a first aid manual.
BACKYARD: The patio has covered outdoor areas equipped with furniture for resident use. There were no bodies of water noted.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility had a central entry point for symptom screening, temperature checks, and sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility does not have a confirmed case of COVID-19 at this time and the LPA reviewed facility’s policies and procedures as it pertains to infection control.

The following deficiency was observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

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

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Salia Walker
LICENSING EVALUATOR SIGNATURE:	DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 09/13/2021 02:28 PM - It Cannot Be Edited

Created By: Salia Walker On 09/13/2021 at 01:21 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: 09/13/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(2)

87705(f)(2) Care of Persons with Dementia: The following shall be stored inaccessible to residents with dementia: Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as the licensee did not ensure that chemicals and cleaning supplies were inaccessible to residents with dementia, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 09/13/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. Items secured during today’s visit. Plan of correction met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Salia Walker

LICENSING EVALUATOR SIGNATURE:

DATE: 09/13/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/13/2021

LIC809 (FAS) - (06/04)

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