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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801851
Report Date: 11/22/2022
Date Signed: 11/23/2022 12:27:26 PM

Document Has Been Signed on 11/23/2022 12:27 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:ROYAL OAKS HOME CAREFACILITY NUMBER:
565801851
ADMINISTRATOR:KAREN ROSALESFACILITY TYPE:
740
ADDRESS:1106 ROYAL AVENUETELEPHONE:
(805) 210-2757
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 4DATE:
11/22/2022
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
11:30 AM
MET WITH:Karina AntigTIME COMPLETED:
03:30 PM
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Licensing Program Analyst (LPA) Teresa Camara conducted a case management-deficiencies visit while visiting the facility regarding an unrelated complaint number 29-AS-20220718164215. LPA met with co-administrator Karina Antig and explained the reason for the visit.

At approximately 11:36 am, while briefly touring the facility, LPA observed Resident 1 (R1) with what appeared to be intravenous (IV) bags being administered. LPA inquired with Staff 1 (S1) about the IV bags and S1 stated R1 has a gastronomy tube (g-tube). S1 stated R1 has had the g-tube since date of admission 6/20/2022.

LPA spoke with the administrator regarding R1's g-tube at approximately 12:30 p.m. The administrator stated when she admitted R1 she was told R1 would be placed on hospice. However, R1's condition started improving and R1 was never put on hospice. R1 receives home health services for the g-tube. R1 has started eating food and R1's gastroenterologist indicated they might remove R1's g-tube. The administrator stated she would contact R1's doctor and request an update. If R1 is not placed on hospice or have the g-tube removed, she will notify R1's responsible party that R1 must be placed in a skilled nursing facility.

Pursuant to Title 22 CA Code of Regulations, the following deficiencies were cited (refer to LIC 9099-D). Exit interview conducted. Today's report and appeal rights were discussed and emailed.
SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 11/22/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 11/22/2022
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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Document Has Been Signed on 11/23/2022 12:27 PM - It Cannot Be Edited


Created By: Teresa Camara On 11/22/2022 at 01:14 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: ROYAL OAKS HOME CARE
FACILITY NUMBER: 565801851

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 11/22/2022
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
11/28/2022
Section Cited
CCR
87615(a)(2)

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87615 Prohibited Health Conditions
(a) Persons who require health services for or have a health condition including, but not limited to, those specified below shall not be admitted or retained in a residential care facility for the elderly:
(2) Gastrostomy tubes.
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Administrator will contact R1's physician to determine if R1 will be placed on hospice as originally planned. If not, R1's responsible party will be contacted and R1 will be immediately relocated to an appropriate facility. Administrator will submit evidence of this to CCL on or before 11/28/2022.
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Based on observation, interview and record review, the licensee did not comply with the section cited above, as R1 has a g-tube, which poses an immediate 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:Teresa Camara
LICENSING EVALUATOR SIGNATURE:
DATE: 11/22/2022
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 11/22/2022


LIC809 (FAS) - (06/04)
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