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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610033
Report Date: 08/09/2021
Date Signed: 08/09/2021 11:57:43 AM

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 VALLEYFACILITY NUMBER:
567610033
ADMINISTRATOR:MALEKSARKISSIANS, JINAFACILITY TYPE:
740
ADDRESS:3110 ROYAL AVETELEPHONE:
(805) 416-8600
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:121CENSUS: 50DATE:
08/09/2021
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:26 AM
MET WITH:Jina Maleksarkissians, AdministtratorTIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Salia Walker conducted an unannounced Case Management - Incident visit to conduct a health and safety check as a result of a resident death, which was reported via telephone at the Woodland Hills North Regional Office on August 6, 2021. Upon arrival, LPA Salia Walker met with Administrator Jina Maleksarkissians at 09:26 a.m. and explained the reason for the visit.

During today’s visit, LPA Walker toured the facility with Health Service Director Daniel Orozco between 09:29 a.m. and 09:57 a.m.

The Department’s Investigation Branch investigator will be investing the death that was reported to LPA Walker. The LPA obtained the requested documents for the Department’s Investigator, which includes the most current Physician’s Report, Admission Agreement, Case Notes, Medication Logs and Emergency and Identification Information.

Exit Interview Conducted. Report Emailed to the Administrator.

SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Salia WalkerTELEPHONE: 818-596-4379
LICENSING EVALUATOR SIGNATURE:

DATE: 08/09/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/09/2021
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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