195850344-4-16-2025-29-AS-ZCHN-DFSUPT-20250416154604

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 195850344
Report Date: 04/16/2025
Date Signed: 04/16/2025 03:47:26 PM

Document Has Been Signed on 04/16/2025 03:47 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 AGOURA HILLS		FACILITY NUMBER:	195850344
ADMINISTRATOR/ DIRECTOR:	CHAPARYAN,LILIT		FACILITY TYPE:	740
ADDRESS:	29353 CANWOOD STREET		TELEPHONE:	(747) 755-5700
CITY:	AGOURA HILLS	STATE: CA	ZIP CODE:	91301
CAPACITY: 102		CENSUS: 85	DATE:	04/16/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:28 AM
MET WITH:	Lilit Chaparyan		TIME VISIT/ INSPECTION COMPLETED:	03:45 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 Analysts (LPAs) Zabel Chochian arrived at the facility unannounced to conduct a required annual visit. Upon arrival LPA met with Executive Director (ED) Lilit Chaparyan and the reason for the visit was stated. LPA completed and reviewed the Entrance Checklist (LIC9242) with the ED. A copy was also provided to ED. LPA met with the Maintenance Director regarding the facility smoke and carbon monoxide detectors; last inspection conducted by Cal Building Systems for the facility fire system alarms and smoke/carbon monoxide detectors on 01/03/2025. Last disaster drill was conducted on 3/15/2025. The LPA along with the facility's Maintenance Director - Martin ,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 inspection began at approximately 11am; the common areas observed included the facility activity rooms, lobby area, library, lounge, café, fitness center, and movie theater All the common areas observed appropriately furnished and clean during todays visit. There is a dedicated area for the posting of required documents directly by the main entrance and hallway. The facility maintained a comfortable temperature. All exits in Memory care have functioning auditory devices and were operational at the time of the visit. Kitchen/dining room toured - Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Dining room furniture observed to be in good condition and appeared to be clean. Emergency food and water supply is stored on the second floor. (Continue to LIC809c)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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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 AGOURA HILLS	FACILITY NUMBER: 195850344
	VISIT DATE: 04/16/2025

NARRATIVE

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A total of eight (8) randomly selected bedrooms were toured - five (5)rooms in the assisted living and three (3) rooms in the memory care unit. During the resident room tour the LPA interviewed five (5) residents.
The resident bedrooms were properly furnished with all required furniture and had sufficient lighting. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. LPA observed all bathrooms in each resident bedroom were clean, properly supplied with hygiene and paper products; all fixtures worked properly. The hot water was measured in each bathroom within 105 - 120 degrees Fahrenheit. Resident alert buttons activated and staff response to the alerts are in a timely manner.

Medications review began at approximately 1pm in the Memory Care unit. The medications are centrally stored in the memory care medication room; medications observed inaccessible to residents; medications observed stored and dispensed as prescribed. The facility has an adequate supply of Personal Protection Equipment (PPE). The facility’s policies and procedures as it pertains to infection control are adequate.

Due to time constraints, the LPA will return at a later date to review staff and resident records including medication procedures and record keeping for the assisted living side.

No health and safety issues observed during today's visit.

Documentation obtained: Copy of the liability insurance, resident roster, staff roster (LIC500), copy of menu, last dieticians report.

Exit interview conducted and copy of the report provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/16/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/16/2025

LIC809 (FAS) - (06/04)

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