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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567610033
Report Date: 06/24/2022
Date Signed: 06/24/2022 04:13:45 PM


Document Has Been Signed on 06/24/2022 04:13 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 VALLEYFACILITY NUMBER:
567610033
ADMINISTRATOR:MALEKSARKISSIANS, JINAFACILITY TYPE:
740
ADDRESS:3110 ROYAL AVETELEPHONE:
(805) 416-8600
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:121CENSUS: 76DATE:
06/24/2022
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
02:36 PM
MET WITH:Chris Andersen and Vivian ReyesTIME COMPLETED:
04:20 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted an unannounced case management visit to investigate two incidents which took place on 06/11/2022. LPA met with Health Services Director (HSD) Vivian Reyes and Executive Director (ED) Chris Andersen.

LPA conducted interviews with the ED and HSD at 2:40 p.m. and obtained pertinent records at 3:10 p.m. LPA conducted a brief inspection of resident rooms for resident 1 (R1), resident 2 (R2), and resident 3 (R3).

LPA will need to conduct additional interviews of staff who were not at the facility during LPA's visit. Further investigation is needed.

No deficiencies observed at this time. Report reviewed with HSD and emailed to both HSD and ED.
SUPERVISOR'S NAME: Jeralyn Ann PfannenstielTELEPHONE: (818) 596-4343
LICENSING EVALUATOR NAME: Teresa CamaraTELEPHONE: 818-326-4019
LICENSING EVALUATOR SIGNATURE:
DATE: 06/24/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/24/2022
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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