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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 405850478
Report Date: 01/07/2025
Date Signed: 01/17/2025 09:00:34 AM

Document Has Been Signed on 01/17/2025 09:00 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:YOKAM'S RCFE # 1NFACILITY NUMBER:
405850478
ADMINISTRATOR/
DIRECTOR:		KAMTO, YOLANDE KONGUEPFACILITY TYPE:
740
ADDRESS:170 S. MESA RDTELEPHONE:
(805) 619-7615
CITY:NIPOMOSTATE: CAZIP CODE:
93444
CAPACITY: 6CENSUS: 5DATE:
01/07/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:02 AM
MET WITH:Cheryll EstacioTIME VISIT/
INSPECTION COMPLETED:
06:00 PM
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Licensing Program Analyst (LPA) Rankin arrived at 10:02 am to conduct a one-year annual visit to the facility above. LPA met with Back-Up Administrator, Cheryll Estacio and explained the purpose of the visit.
A tour of the inside and outside of the facility was conducted. The following was inspected and noted during the annual visit:
Physical Plant & Environment Safety: The facility has 5 resident bedrooms, 2 bathrooms and currently occupies 5 residents. LPA was authorized to enter and inspect facility. The facility has smoke and carbon monoxide detectors that were tested and working properly during visit. The lighting and lamps are sufficient for the use of the facility and for resident comfort. Toilet, hand washing and bathing facilities are operational and secured grab bars are present. The showers have non-skid mats or textured bottoms. A schedule for resident’s showers was posted on the refrigerator door. All residents require assistance in bathing so a plan to ensure all residents received their showers is tracked. The pathways are clear of any obstructions. Facility is well lit inside and outside for safety. Disinfectant, cleaning solutions and poisons are inaccessible to residents in care locked under sink. The facility has sufficient space inside and outside for activities and visiting. The facility has a fenced backyard, LPA requested updates to the gate on the right front facing side of the facility to ensure it self-closes. The facility has telephone and internet service for resident use.

Operational Requirements: The facility has a current plan of operation on file with the department. The facility has current liability insurance and expires on 01/07/26. The facility is approved for a capacity of six. The fire clearance is granted for 6 non-Ambulatory of which four may be bedridden. Hospice is approved for four.

Staffing: The facility currently employes four full time staff and two Administrators. Staff files were reviewed. LPA observed recent Health Screening done on 1/6/25 that stated “able to provide assistance without significant lifting/pushing/pulling” done for two staff, administrator will need to assess the support required to ensure the safety of residents in care. Current Administrator Certificate expires June 18, 2026.

Continued 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE: DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/07/2025
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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STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: YOKAM'S RCFE # 1N
FACILITY NUMBER: 405850478
VISIT DATE: 01/07/2025
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Personnel Records & Training: The facility keeps confidential files for each staff member. Staff have annual training on various topics noted in their records. Training for 2024 needs to be updated. Licensee will provide LPA updated schedule of topics needing to be addressed to ensure staff are trained on all regulation required topics.

Resident Records & Incident Reports: The facility keeps separate files on each resident confidential. Facility does submit incident reports to the department when required. LPA reviewed five resident files for signed Admission Agreements, Physician Reports, Annual Needs and Services Plans, and other required documents and found all required documents. In addition, LPA viewed Hospice binders for residents on Hospice which included care notes, plans, training's and orders.

Medication Review: LPA conducted a medication review. Medication was documented on a Centrally Stored Medication Record as well as tracked on Medication Administration Records. All medication and records were found to be updated and in compliance with regulations. Training required for medication was not found in staff records and will be requested by LPA.

Food Service: The facility handles and prepares food safely. The facility has 2-day perishables and 7-day non-perishables to meet the food service requirement. All food is covered, stored, and marked appropriately. Food, snacks and drinks are available when the residents want them. Cleaning solutions and equipment are stored separately from food supplies. Kitchen staff are observed for personal hygiene and food sanitation practices. At time of visit LPA observed individual meals being prepared for residents as they were ready for their meals.

Disaster Preparedness: The current emergency disaster forms were posted. Emergency exits and telephone numbers were posted. Drills are conducted quarterly. A set of keys is available for staff on all shifts to access full facility in an emergency.

Residents with Special Health Needs: The facility does accept dementia residents in care. The facility currently has residents receiving Hospice services. Facility has a planned activities schedule on the refrigerator door with various activities scheduled to engage residents. Exit door alarms are working.

Exit interview conducted, copy of report, issued.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Melisa Rankin
LICENSING EVALUATOR SIGNATURE:

DATE: 01/07/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025
LIC809 (FAS) - (06/04)
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