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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850039
Report Date: 08/11/2023
Date Signed: 08/11/2023 04:23:37 PM

Document Has Been Signed on 08/11/2023 04:23 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:OAK PARK MANORFACILITY NUMBER:
405850039
ADMINISTRATOR:MEFFERT, ASTRIDFACILITY TYPE:
740
ADDRESS:1073 OLD OAK PARK ROADTELEPHONE:
(805) 540-1503
CITY:ARROYO GRANDESTATE: CAZIP CODE:
93420
CAPACITY: 32CENSUS: 20DATE:
08/11/2023
TYPE OF VISIT:Case Management - Annual ContinuationUNANNOUNCEDTIME BEGAN:
10:45 AM
MET WITH:Astrid Meffert, AdminsitratorTIME COMPLETED:
03:40 PM
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Licensing Program Analyst (LPA) De Leon arrived at 10:45 am to conducted a 1 year annual visit to the facility above. LPA met with Astrid Meffert, Administrator and explained the purpose of the visit.

Staffing: The facility employes 20 staff and 3 Administrators. Staff records are kept confidential. Files reviewed had current 1st Aid/CPR, Personnel Records/Application, Health screening with TB results, Criminal Record statements, and Finger print clearance/Associations/exemptions. Administrator file was reviewed for Continuing Education requirements and current Administrator Certificate. Administrator Certificate expires 05/17/2024.
Personnel Records & Training: The facility keeps confidential files for each staff member. LPA reviewed 5 staff training records for Initial and/or Annual Training Requirements of 20 plus hours meeting 8 hours of dementia training with all subjects covered over a 3 year period, 4 hours of hospice care, postural supports and restricted health condition, and 8 hours of other training to include ADL's, resident characteristics, emergency preparedness policy and procedures, infection control requirements and Quarterly Disaster Drills. Staff handling medications had annual training of 8 hours of medication training. Kitchen staff had training on facility policy and procedures for food handling and preparation as well as infection control requirements, some staff had food handler certificates. Trainers met the requirements to train staff with required information on file. Hospice and Home Health provide training to staff for residents under those services and facility keeps records on file. One out of five staff did not meet the full hours and topics covered, facility will provide the training thorough Relias for the hours and topics required.
Resident Records & Incident Reports: The facility keeps separate files on each resident confidentially. Five files were reviewed for signed Admission Agreements, Medical Assessments, LIC. 602A Physicians Report, ID and Emergency contact forms, Appraisal Needs and Services plans (ANS), TB results, Personal Rights, and Safeguard for personal property and valuables. Pre-Admission appraisals are conducted on perspective residents before accepting them into care. The Facility does not handle cash resources on residents in care. Facility does submit incident reports to the department when required. Cont. 809-C
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE: DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 08/11/2023
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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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: OAK PARK MANOR
FACILITY NUMBER: 405850039
VISIT DATE: 08/11/2023
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Resident Rights Information: All require postings were posted in the common area of the facility. Personal rights, Rights to Resident Council, Theft and Loss policy, and Non-discrimination notice. CCL Complaint poster and LTCO poster were posted in the common areas of facility. The current license along with CCL reports and PIN's were posted. Visitation policy is posted at entry. Internet and a device for residents use is provided to resident with confidentiality and privacy.

Incidental Medical and Dental Services: Facility provides or assists in providing transportation to medical and dental appointments when needed. The facility uses the Medication Administration Record (MAR) along with the Centrally Stored Medication and Destruct Records (CSMDR). Medications are kept in a locked medication cart. Medication were checked for expiration. Medication labels were not altered and medication were stored in original containers. Administrator and Medication Technicians destroy medications together.

LPA conducted interviews with 3 residents and 3 staff.

Exit interview conducted and copy of report printed for Administrator.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Rachael De Leon
LICENSING EVALUATOR SIGNATURE:

DATE: 08/11/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 08/11/2023
LIC809 (FAS) - (06/04)
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