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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197606758
Report Date: 07/15/2022
Date Signed: 07/28/2022 11:40:56 AM

Document Has Been Signed on 07/28/2022 11:40 AM - 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:CHATEAU OF OAKSFACILITY NUMBER:
197606758
ADMINISTRATOR:ROLANDO & LILY LAZATINFACILITY TYPE:
740
ADDRESS:15239 CAMARILLO STREETTELEPHONE:
(818) 510-0080
CITY:SHERMAN OAKSSTATE: CAZIP CODE:
91403
CAPACITY: 6CENSUS: 5DATE:
07/15/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
12:32 PM
MET WITH:Rolando LazatinTIME COMPLETED:
04:30 PM
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On 07/12/2022, Licensing Program Analyst (LPA) Sandra Urena, arrived at the facility at 12:32 p.m., unannounced to conduct a required annual inspection. This annual inspection had a specific emphasis on infection control practices, and procedures. LPA Urena met with Administrator Rolando Lazatin, and explained the reason for the visit.

Infection Control: The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19.

At 12:45 p.m., LPA Urena, and administrator conducted a tour inside, and outside the facility to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

Common Areas: At 12:50 p.m., LPA Urena observed the walls and flooring to be clean and in good condition. The common seating area, and dining room furniture was observed to be clean and in good condition. Fire extinguisher was observed to be serviced within the last year.

Kitchen: At 12:50 p.m., LPA Urena, and administrator observed the kitchen/dining area. Knives are stored in a locked cabinet drawer. Kitchen appliances were in operable condition. The facility has enough supply of perishable and non-perishable food. Freezer and refrigerator are stocked with a variety of foods. Emergency food supply is adequate for six residents and two staff. Toxic materials are locked, and out of reach of residents.

Bedrooms: At 1:10 p.m., LPA Urena, and administrator observed residents’ bedrooms. Four bedrooms were furnished appropriately with appropriate furnishings and sufficient lighting. Linens are clean and in good condition. Extra linens were observed in the bedroom closets.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE: DATE: 07/18/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/18/2022
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: CHATEAU OF OAKS
FACILITY NUMBER: 197606758
VISIT DATE: 07/15/2022
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Bathrooms: At 1:15 p.m., LPA Urena, and administrator observed the residents’ restrooms. Restrooms were clean, shower area was in clean condition with grab bars, and a non-skid mat available. Paper towels were available for drying hands. Handwashing signs were displayed, and sufficient amounts of soap, and paper products in each restroom. Hallway: The hallway in bedroom #4 needs to be clear of boxes that are being stored in the hallway leading from the bedroom to the bedroom’s bathroom.

Outdoor Space: At 1:20 p.m., LPA Urena, and administrator observed the outdoor space. Backyard has a patio area; however, the patio has items that need to be removed in order to be clean, and to be utilized by residents, and their visitors. The following items were observed: file cabinet, torn canopy shade, wheelchair, bicycle, and debris. The right side of the patio has wooden planks that are a walking hazard. No open bodies of water were noted.



Right side of the house Walkway. At 1:40 p.m., LPA Urena, and administrator observed the following: The right side wooden fence, leading from the front of the house to the backyard is leaning to the side, and is wobbly. The neighbor’s tree branches are obstructing the walkway. A clothing line spanning from the front of the house to the back with hanging clothes is obstructing the walkway.

Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D).

Citations were issued. Exit interview was conducted with the Administrator. A copy of the report, and the Appeal Rights were issued. Licensee will sign the report, and return to CCLD office via email.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Sandra Urena
LICENSING EVALUATOR SIGNATURE:

DATE: 07/12/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/12/2022
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/28/2022 11:40 AM - It Cannot Be Edited


Created By: Sandra Urena On 07/12/2022 at 02:32 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: CHATEAU OF OAKS
FACILITY NUMBER: 197606758

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/15/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
07/22/2022
Section Cited

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87303(a) Maintenance and Operation. The
facility shall be clean, safe, sanitary, and in
good repair at all times…This requirement is
not met as evidenced by:
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Based on the observation, the
licensee did not comply with the section cited
above, as the backyard patio area was found to be encumbered with debris, which poses a potential health and safety risk to residents in care.
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Type B
08/26/2022
Section Cited

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87303(a) Maintenance and Operation. The
facility shall be clean, safe, sanitary, and in
good repair at all times…This requirement is
not met as evidenced by:
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Based on the observation, the licensee did not comply with the section cited above, as the wood fence is wobbly, and leaning. The passage from the front to the back of the house is partially blocked with tree branches and clothing line...which poses a potential health and safety risk to residents in care.
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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
LICENSING EVALUATOR NAME:Sandra Urena
LICENSING EVALUATOR SIGNATURE:
DATE: 07/12/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/12/2022


LIC809 (FAS) - (06/04)
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