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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 197608657
Report Date: 09/28/2023
Date Signed: 09/28/2023 04:38:06 PM

Document Has Been Signed on 09/28/2023 04:38 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
Lookup Error,
, CA
FACILITY NAME:OAKRIDGE INNFACILITY NUMBER:
197608657
ADMINISTRATOR:ROMIK ROSTOMYANFACILITY TYPE:
740
ADDRESS:1281 OAKRIDGE DRIVETELEPHONE:
(818) 482-9117
CITY:GLENDALESTATE: CAZIP CODE:
91205
CAPACITY: 6CENSUS: 5DATE:
09/28/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:24 PM
MET WITH:Romik RostomyanTIME COMPLETED:
04:57 PM
NARRATIVE
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Licensing Program Analyst (LPA) Alberto Lopez conducted the required annual inspection. LPA arrived unannounced and met with DSP Monika Tagvoryan who allow LPA entry and Administrator Romik Rostomyan arrived a short time later and assisted with the inspection today. The facility is licensed for 6 residents ages 60 and over. The fire clearance is approved for Six (6) non-ambulatory residents of which 1 can be bedridden. There is a hospice waiver approved for 2 residents. Currently there are 5 residents at the facility.

LPA utilized the Compliance and Regulatory Enforcement (CARE) tools for the visit today and observed the following:

Infection Control: The facility staff are using appropriate hand hygiene and gloves while assisting residents with medications. Disposals of trash are done immediately after changing a resident. Staff are still cleaning and disinfecting throughout the day. Facility has sufficient PPE supplies and has an Infection Control Plan needs updating.
Operational Requirements: A current Plan of Operation was reviewed. Liability Insurance policy in the amount of $1,000,000.00 each occurrence and #3,000,000.00 in the total annual aggregate is valid and will expire on 10/05/2023. The last fire Drill was conducted on 02/05/2023. Care and supervision to meet the residents needs was observed.
Physical Plant & Environment Safety: The facility is a single-story building. Common areas, including the living room, dining room, all appeared clean and were properly furnished except some rooms are missing chairs. The kitchen appeared clean and the appliances and fixtures functional. Entry/exits were free of obstruction. The medications were locked in the medication room. The 3 resident rooms were inspected, and the water temperature measured between 121.6-126.3 degrees F which is not within range of 105 – 120 degrees F.
Staffing: There appears to be sufficient staffing at the facility. The Administrator’s certificate expires 11/18/2024 Staff employed are all over the age of 18.
Personnel Records-Training: Staff files are maintained at the facility. Staff have current CPR/first aid training and evidence of some on-going training.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE: DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/28/2023
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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Document Has Been Signed on 09/28/2023 04:38 PM - It Cannot Be Edited


Created By: Alberto Lopez On 09/28/2023 at 04:09 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
,
, CA

FACILITY NAME: OAKRIDGE INN
FACILITY NUMBER: 197608657

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/28/2023

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87303(e)(2)
Maintenance and Operation
(e) Water supplies and plumbing fixtures shall be maintained as follows: (2) Faucets used by residents for personal care such as shaving and grooming shall deliver hot water. Hot water temperature controls shall be maintained to automatically regulate the temperature of hot water used by residents to attain a temperature of not less than 105 degree F (41 degrees C) and not more than 120 degree F (49 degrees C).

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Water temperature measured 121.6 -126.3 degrees F which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 09/29/2023
Plan of Correction
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Administrator will adjust water temperature and send proof to LPA by POC date.
Type A
Section Cited
CCR
87465(h)(5)
Incidental Medical and Dental Care Services
(h) The following requirements shall apply to medications which are centrally stored: (5) Each resident's medication shall be stored in its originally received container. No medications shall be transferred between containers.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and interview, the licensee did not comply with the section cited above 1 of 5 residents medications was transferred between containers. which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/30/2023
Plan of Correction
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Administrator will conduct training for all staff and send proof to LPA by POC date.
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:Lisa Hicks
LICENSING EVALUATOR NAME:Alberto Lopez
LICENSING EVALUATOR SIGNATURE:
DATE: 09/28/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/28/2023


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
Lookup Error,
, CA
FACILITY NAME: OAKRIDGE INN
FACILITY NUMBER: 197608657
VISIT DATE: 09/28/2023
NARRATIVE
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Resident Records-Incident Reports: Resident files are maintained at the facility and have the following documents in their files - Admission Agreements, Identification & Emergency Information, current Physician's Report, Pre-admission appraisal/Appraisal Needs & Services Plan.
Resident Rights-Information: The Complaint poster and Residents personal rights are posted by the main entry. Visiting hours are not posted.
Planned Activities: Facility has sufficient space to accommodate indoor and outdoor activities. There are sufficient supplies and equipment to meet resident's physical capability.
Food Service: The kitchen was inspected and has sufficient supply of 2-day perishable & 7-day non-perishable food. Kitchen, food preparation area, and storage areas were observed to be clean and sanitary. The food is properly stored in the refrigerator (clean, labeled and well maintained). Pesticides and cleaning supplies are kept away from the food preparation areas. Kitchen is kept clean and free from rodents.
Incidental Medical & Dental: The medications are centrally stored and but not in original containers. During the visit today, LPA reviewed 5 residents' medication files and all medications are administered according to Doctor’s orders.
Disaster Preparedness: The facility has an Emergency Disaster and Mass Casualty Plan containing emergency evacuation, storage and preservation of medications, The facility conducts emergency drill every 6 months but needs to conduct emergency drill quarterly. for all staff and residents.
Residents with Special Health Needs: No residents have prohibited health conditions.

Deficiencies cited (See 809D) and technical advisories were also provided. An exit interview was held. A copy of this report, LIC809D, technical advisory notes, and appeal rights were given to Romik Rostomyan

SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Alberto Lopez
LICENSING EVALUATOR SIGNATURE:

DATE: 09/28/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/28/2023
LIC809 (FAS) - (06/04)
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