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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609831
Report Date: 10/01/2024
Date Signed: 10/01/2024 02:19:09 PM


Document Has Been Signed on 10/01/2024 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



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: 48DATE:
10/01/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:25 AM
MET WITH:Holly GoldTIME COMPLETED:
02:35 PM
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Licensing Program Analyst (LPA) Angela Barutyan arrived at the facility unannounced to conduct a required annual visit at 9:25AM. Upon arrival, LPA met with Administrator Holly Gold and explained the reason for the visit. Entrance interview conducted.

Beginning at 09:32AM, the LPA, along with the Administrator, 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. The following was observed:

COMMON AREAS: The common areas include two (2) lounges, two (2) outdoor patios, dining room, activity room, beauty salon, and book nook. LPA observed required postings throughout the common area. Common areas were observed to be properly furnished with enough seating to accommodate residents and with appropriately screened fireplace. The facility maintained a comfortable temperature. LPA tested auditory exit device at 09:51AM, exits were observed to have functioning auditory devices and were operational at the time of the visit. Fire extinguishers throughout the facility were fully charged and were last serviced 04/09/2024. Fire system devices are tested annually and were last tested 06/06/2024.

BEDROOMS: LPA inspected eleven (11) randomly selected bedrooms between 09:42AM – 11AM. Resident bedrooms were properly furnished with a bed, night stand, chest of drawers, closet space, and sufficient lighting for each resident. Bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. At 09:42AM, LPA observed stained carpets in room 1. At 09:51AM, LPA observed food crumbs and stains on the carpet in room 38. At 10:52AM, LPA observed a hole about 4 inches in size on the lower portion of the bathroom door, a broken dresser with a loose drawer that poses a safety hazard if it were to fall, and stained carpets in room 44. Administrator immediately replaced the broken dresser and will schedule a carpet shampooing.


Report Continued on LIC 809
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 INN
FACILITY NUMBER: 567609831
VISIT DATE: 10/01/2024
NARRATIVE
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BATHROOMS: Resident bathrooms are shared between rooms with door access from each. Some bedrooms have private bathrooms that are not shared. LPA observed bathrooms in each resident bedroom to be clean and properly supplied with functional grab bars and fixtures. LPA observed pull cords by the toilet. Hot water was measured in five (5) bathrooms and was between 106.1 – 117.4 degrees Fahrenheit, which is within the required range. There are eight (8) shower rooms, however, four (4) are in use. Shower rooms were observed to be clean, sanitary, in operating condition with non-skid surfaces, and sufficiently stocked with linens and personal hygiene supplies.

KITCHEN: At 10:21AM, LPA toured the kitchen. The kitchen is kept inaccessible to residents in care. Knives and sharps 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 10:22AM, LPA observed a dented can of tomatoes, staff discarded can immediately, and observed enchilada sauce stored in an old cottage cheese container without dates or labels. Kitchen staff stated that the enchilada sauce was made one week ago. At 10:23AM, LPA observed two (2) containers of expired Lactaid Milk (expired 09/16/2024 and 09/29/2024). Staff immediately discarded expired items. At 10:28AM, LPA observed unlabeled and undated meats stored in the freezer that were gray in color and had freezer burn. Kitchen staff stated they will go through the freezer and remove all unlabeled and undated items.

MEDICATION REVIEW: LPA began medication review at 10:29AM and reviewed medications for three (3) residents. Medications are centrally stored in the medication room by the business office. Medications are prepped up to 24 hours in advance in medication cups. All medications reviewed were stored and documented per regulation.

RECORDS REVIEW: Beginning at 11:14AM, LPA reviewed five (5) personnel and five (5) residents files for documents including but not limited to: resident Admission Agreement, resident physician’s report, TB test, health screening, staff training and fingerprint clearance. All five (5) personnel and resident files reviewed were in compliance with regulation at the time of the visit.

Report Continued on LIC 809
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 2 of 5
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		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 INN
FACILITY NUMBER: 567609831
VISIT DATE: 10/01/2024
NARRATIVE
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INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 08/17/2024.

INTERVIEWS: During today’s visit, LPA interviewed three (3) residents and three (3) staff.

During today’s visit, LPA obtained a copy of the facility’s liability insurance.

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:

DATE: 10/01/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 10/01/2024 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ROYAL OAKS INN
FACILITY NUMBER: 567609831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87555(b)(8)
General Food Service Requirements
(b) The following food service requirements shall apply: (8) All food shall be of good quality. Commercial foods shall be approved by appropriate federal, state and local authorities. Food in damaged containers shall not be accepted, used or retained.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that two food items were expired, one can was dented, multiple food items were not labeled or dated, and meats in the freezer had freezer burn, which poses an immediate health and safety risk to persons in care.
POC Due Date: 10/02/2024
Plan of Correction
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Staff discared expired items and dented can immediately. Staff will discard freezer burn items and unlabeled and undated items. Administrator agrees to provide an in-service training on food safety and storage and ensures that food items will be labeled and dated. Administrator will submit proof of in-service training to CCL by 10/02/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 4 of 5


Document Has Been Signed on 10/01/2024 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364


FACILITY NAME: ROYAL OAKS INN
FACILITY NUMBER: 567609831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/01/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87303(a)
Maintenance and Operation
The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above in that three resident bedrooms contained stained carpets and one bedroom contained a broken dresser and a hole in the bathroom door which poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 10/15/2024
Plan of Correction
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Staff immediately replaced the broken dresser. Administrator agreed to contact a repair person to fix the door and will have a carpet cleaning service for resident rooms. Administrator will submit invoive, receipt, or photographic proof to CCL by 10/15/2024.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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 HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Angela BarutyanTELEPHONE: 747-922-1234
LICENSING EVALUATOR SIGNATURE:
DATE: 10/01/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/01/2024
LIC809 (FAS) - (06/04)
Page: 5 of 5