567609831-9-2-2022-29-AS-ASMH-CHVUUB-20220902155316

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609831
Report Date: 09/02/2022
Date Signed: 09/02/2022 03:53:48 PM

Document Has Been Signed on 09/02/2022 03:53 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: 61	DATE:	09/02/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	02:15 PM
MET WITH:	Brandon Jakobovich		TIME COMPLETED:	04:00 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 Analyst (LPA) Ashley Smith arrived unannounced to conduct a required annual visit, which has an emphasis on infection control practices and procedures. The LPA met with Administrator Brandon Jakobovich and informed them of the reason for the visit.

The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations.

Kitchen: The facility had a sufficient supply of two-day perishable and seven-day nonperishable food. Food is prepared based on the resident’s diets. Facility uses Sysco Foods for food deliveries. Snacks and beverages are available for residents.

Common Areas: The building is a one-level facility, which consists of several offices, several activity rooms, medication room, laundry room, multiple supply closets, beauty parlor, staff room, kitchen/dining room, and multiple shower rooms. There were no obstructions and/or tripping hazards throughout the facility. The facility maintains a comfortable temperature. There are fire extinguishers throughout the facility, which were charged and last serviced 5/2022. Planned activities are offered. Activity schedule is posted throughout the facility. The LPA observed staff engaging residents in group activities. All activity rooms and common spaces appeared clean and in good repair.

Bedrooms/Restrooms: Rooms had appropriate furniture and sufficient lighting. Each bathroom in the resident’s room is 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 non-skid material in the showers. Restrooms were stocked with paper towels and soap. Hot water was randomly tested throughout the facility inspection; levels were adjusted during the visit and water registered within range.

Outside areas: The courtyard had appropriate furniture, with a covered shaded area for residents. Parking is available for residents and visitors. No bodies of water noted.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)

Page: 1 of 2

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: 09/02/2022

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

Infection Control: There is a central entry point for universal screening and temperature checks for visitors. Staff were observed wearing appropriate face masks. There is a centralized location with COVID-19 signs that promoted hand hygiene, physical distancing, and cough/sneeze etiquette. There is an adequate supply of Personal Protection Equipment (PPE) and additional supplies can be obtained. The facility’s cleaning protocol is sufficient. This facility has records of staff and resident vaccinations. The facility can designate a single-person room to isolate persons if there is a confirmed case of COVID-19. Staff are up to date regarding guidelines around visitation and vaccine requirements. The facility has previously managed COVID-19 active cases and the facility complied with all requirements set forth by the local health department and licensing. The community's policies and procedures as it pertains to infection control are adequate.

No deficiencies observed at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 09/02/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/02/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2