567610033-3-9-2022-29-AS-TCAA-CCD336-20220309165258

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567610033
Report Date: 03/08/2022
Date Signed: 03/09/2022 04:54:07 PM

Document Has Been Signed on 03/09/2022 04:54 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:	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:	DATE:	03/08/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:21 PM
MET WITH:	Michael Fountain		TIME COMPLETED:	04:08 PM

NARRATIVE

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Licensing Program Analyst (LPA) Teresa Camara arrived at the facility unannounced to conduct a required annual visit at 01:21 p.m. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Regional Director of Operations Michael Fountain who is currently acting as Executive Director/Administrator and explained 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 the facility is in compliance with Title 22 Regulations. The fire extinguishers are inspected monthly by maintenance staff and annually by a service. The carbon monoxide and smoke alarms were last tested 01/20/22 by Cal Building Systems and all functioned properly.

KITCHEN: The commercial kitchen was clean and appliances all appeared operable. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The LPA observed randomly chosen rooms in both assisted living and memory care. Rooms were appropriately furnished, clean and had sufficient lighting.

RESTROOMS: Restrooms inside the randomly chosen rooms were clean and sanitary and in operating condition. One room (#129) in memory care had a can of Lysol accessible to the resident and one room (#132) in memory care had two cans of room deodorizer accessible to the resident.

COMMON SPACES: The lobby, activity rooms, dining rooms, lounge areas, a theater, gym, and hair salon were all appropriately furnished and in good condition. The LPA observed the required postings throughout the facility. The patio areas in both memory care and assisted living were equipped with furniture for residents' use.

(continued on 809-C)

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

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: 03/08/2022

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(continued from 809)

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening and sanitation station. All facility staff were observed wearing masks. The facility has an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility has appropriate plans in place in the event of clients and/or staff showing symptoms of COVID or testing positive for COVID.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Exit interview conducted. Today's reports and appeal rights were discussed. A copy of the report was emailed to the Administrator.

SUPERVISOR'S NAME: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 03/09/2022 04:54 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: OAKMONT OF SIMI VALLEY	FACILITY NUMBER: 567610033
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 03/08/2022

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 03/15/2022 Section Cited	1 2 3 4 5 6 7	87705 Care of Persons with Dementia (f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.
	8 9 10 11 12 13 14	This requirement is not met as evidenced by: LPA observed Lysol and Febreeze accessible to residents in memory care in rooms #129 and #132, which poses an immediate health, safety or personal rights risk to persons in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7
	1 2 3 4 5 6 7

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: Jeralyn Ann Pfannenstiel	TELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa Camara	TELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:	DATE: 03/08/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 03/08/2022

LIC809 (FAS) - (06/04)

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