567609831-10-20-2023-29-AS-BBAI-CWSSYR-20231020141757

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609831
Report Date: 10/20/2023
Date Signed: 10/20/2023 02:19:26 PM

Document Has Been Signed on 10/20/2023 02:19 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: 52	DATE:	10/20/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:30 AM
MET WITH:	Holly Gold - Executive Director		TIME COMPLETED:	02:45 PM

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	Licensing Program Analysts (LPAs) Brian Balisi and Martha Arroyo arrived at the facility unannounced to conduct a required annual visit at 9:30am. Upon arrival LPAs met with Administrator Holly Gold and explained the reason for the visit. At approx. 10am LPAs 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. Common Areas: LPAs inspected the common areas throughout the facility. The common areas include two (2) lounges, (2) outdoor patios, Dining room, activity room and book nook. There is a dedicated area for the posting of required documents directly by the Medication room. The common areas were observed to be properly furnished and relatively clean at the of the visit. LPA observed appropriate signage regarding infection control posted throughout the facility. At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Smoke detector(s) and carbon monoxide detectors were operational at the time of the visit. Fire extinguishers were observed throughout the facility, fully charged and were last serviced May 18, 2023. All exits were observed to have functioning auditory devices and were operational at the time of the visit. The LPAs observed required postings throughout the common spaces. Bedrooms: At approximately 10:10am, LPAs inspected (6) randomly selected bedrooms. The resident bedrooms were properly furnished with a bed, night stand, and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms in each resident bedroom were clean, properly supplied and had functional fixtures. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. At 10:20am LPAs observed multiple personal hygiene items in Room 16 , easily accessible to residents in care. At 10:32am LPAs observed hand lotion in Room 49., easily accessible to residents in care.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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 10/20/2023 02:19 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 10/20/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(g)

Care of Persons with Dementia

(g) As required by Section 87468(a)(12), residents with dementia shall be allowed to keep personal grooming and hygiene items in their own possession, unless there is evidence to substantiate that the resident cannot safely manage the items. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation and records review the licensee did not comply with the section cited above as personal hygenie items were found to be easily accessible to residents in care in rooms #16 and #49, based on records review R1 and R2 are at risk if allowed to have access to personal grooming and hygeiene items, which poses an immediate health and safety risk to persons in care.
	POC Due Date: 10/23/2023
	Plan of Correction
1 2 3 4	Licensee immediatley made items inaccessible. Licensee also agreed to review section cited and provide a statment of understanding and provide to CCL via email be EOD 10/23/2023.

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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: 10/20/2023

NARRATIVE

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Continued from 809
There are 5 shower rooms . LPAs observed shower rooms were clean, sanitary and in operating condition with non-skid surfaces. The shower rooms were sufficiently stocked with supplies of linen and personal hygiene supplies.

LPAs observed kitchen was inaccessible to residents in care. Knives are kept inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At approximately 10:17am the LPAs observed non-perishable items in poor condition – Mint Jelly (expired 08/27/2023). LPAs observed staff immediately discard expired items. Dining room furniture were observed to be in good condition and appeared to be relatively clean. LPAs observed staff cleaning the dining room. At approximately 11:45am, LPAs observed residents having lunch in dining room.

Records review began at 10:55 am, six (6) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. Six (6) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. Last emergency disaster drill was conducted - 8/23/2023 Evacuation Drill

Medications review began at approximately 1:30pm The medications are centrally stored in a med room on the first floor. Medications are properly documented on the centrally stored medications and destruction record.

Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of Communicable disease. The facility has 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 a communicable disease. The facility’s policies and procedures as it pertains to infection control are adequate.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

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: 10/20/2023

NARRATIVE

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Continued from 809-C

Between 12pm - 1pm the LPAs interviewed six (6) staff and four (4) residents.

The following deficiencies were 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

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 10/20/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/20/2023

LIC809 (FAS) - (06/04)

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