567610033-3-4-2021-29-AS-ASMH-BYSSTJ-20210304130937

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610033
Report Date: 03/04/2021
Date Signed: 03/04/2021 01:10:30 PM

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:	OAKMONT OF SIMI VALLEY		FACILITY NUMBER:	567610033
ADMINISTRATOR:	MALEKSARKISSIANS, JINA		FACILITY TYPE:	740
ADDRESS:	3110 ROYAL AVE.		TELEPHONE:	(805) 416-8600
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	121	CENSUS: 0	DATE:	03/04/2021
TYPE OF VISIT:	Prelicensing	ANNOUNCED	TIME BEGAN:	09:00 AM
MET WITH:	Jina Maleksarkissians, Executive Director		TIME COMPLETED:	01:30 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 at the facility at 9am for an announced pre-licensing inspection. Upon arrival, the LPA met with Executive Director Jina Maleksarkissians. The applicants successfully completed Component II on 2/10/2021 and Component III on 3/2/2021. A fire clearance was approved on 8/18/2020 and all rooms were cleared for non-ambulatory use. All rooms were cleared for bedridden use; however, this facility shall be limited to a maximum capacity of eight (8) bedridden residents. This facility has an approved Hospice Waiver for eight (8) residents. COMMON AREAS: The physical plant tour took place at 9:05am. The facility is a two story building. Facility has 2 working elevators and 3 stairwells. On the first floor, there are the kitchen facilities, dining room, Bistro, laundry rooms, medication room, bar/lounge area, library, activity rooms, formal sitting areas, beauty salon, fitness center, Wellness Center, office rooms, and common restrooms. On the second floor, there is a media room, laundry rooms, and common restrooms. The LPA observed fireplaces in the first floor dining area, library/reading room, the Bistro, and the formal sitting room. The LPA observed common areas to be clean and in good condition. There were no obstructions and/or tripping hazards throughout the facility. The facility uses a signal system, which is activated via pull cord in resident units and common areas. Alerts are sent to the front desk but also to pagers, which will be carried by staff. Residents will also have the option to use a pendant. Wanderguard will be offered to residents as needed. System was tested randomly throughout the visit and it was in operating condition. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted throughout the facility. Other required postings were posted in the large activity room on the first floor. CONT 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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: OAKMONT OF SIMI VALLEY	FACILITY NUMBER: 567610033
	VISIT DATE: 03/04/2021

NARRATIVE

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There are fire extinguishers throughout the facility, which were serviced 08/2020. The building received a final inspection from the fire department on 8/18/2020 and smoke detectors, sprinkler system, and carbon monoxide detectors were observed to be in operating condition. During today’s inspection, the smoke detectors and carbon monoxide detectors were tested randomly in resident units and all were in operable condition. Smoke detectors are hard-wired in the facility common areas. The LPA obtained appropriate documentation regarding the fire inspection for the hard file.

The LPA toured the outside area of the facility. There are three outdoor gated courtyards: one is designated for Memory Care residents and the other two are designated for Assisted Living residents. The LPA observed appropriate outdoor furniture, with a covered shaded area for residents. Facility has a 20-seat passenger bus for transportation needs. There is parking available for resident use, including 8 garage spaces.

MEDICATION: There were two medication rooms on the first floor; one is designated for Assisted Living residents and the other for Memory Care residents. There were several complete first-aid kits and a surplus of medical supplies. The medication carts are equipped with a double locking system for narcotics.

KITCHEN: The main kitchen and dining room are located on the 1st floor. Food is prepared in the main kitchen and delivered to the dining area and the Memory Care dining room. Facility dining room and commercial kitchen were inspected and found to be in compliance with Title 22 regulations. Facility uses Sysco Foods for food deliveries, and food delivery takes place twice a week. The facility has a seven day emergency supply of food and water, which was observed to be in good condition at the time of the visit.

RESIDENT ROOMS: Memory Care is located on the first floor and has 29 rooms. Out of the 29 rooms, 5 are identified for double occupancy. The Memory Care Unit has all studio apartments with no appliances. There is a separate dining space for Memory Care residents, and food will be prepared in the main kitchen and brought into the dining space for meals. All rooms in the Memory Care Unit are complete, with properly installed grab-bars in resident bathrooms and non-skid surfaces in shower tubs. There are motion sensors installed in all Memory Care units. Delayed egress was tested in the Memory Care unit and it was operational at the time of the visit.

CONT 809-C

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

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: OAKMONT OF SIMI VALLEY	FACILITY NUMBER: 567610033
	VISIT DATE: 03/04/2021

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RESIDENT ROOMS (cont): There are 52 Assisted Living units and can be found on the first and second floor of the building. Assisted Living units are either studio, one, or two bedroom units and rooms and are equipped with a refrigerator, sink, and microwave. All rooms in the Assisted Living Unit are complete, with properly installed grab-bars in resident bathrooms and non-skid surfaces in shower tubs.

During today's visit, water temperature was tested throughout the units and temperature ranged between 106 to 116 degrees Fahrenheit, which is within the required range per regulation of 105 to 120 degrees Fahrenheit.

Physical plant is in compliance with Title 22 regulations. This report will be sent to the Centralized Application Bureau (CAB). The CAB Analyst will notify the applicant when the license has been approved. The applicant is aware that they are unable to operate until they have been notified that the license has been approved by the CAB Analyst. Failure to comply could affect approval of the license. Exit interview conducted and report issued via email.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Ashley Smith	TELEPHONE: (818) 421-9032
LICENSING EVALUATOR SIGNATURE:	DATE: 03/04/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/04/2021

LIC809 (FAS) - (06/04)

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