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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565801851
Report Date: 02/03/2025
Date Signed: 02/03/2025 03:41:45 PM

Document Has Been Signed on 02/03/2025 03:41 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/
DIRECTOR:
KAREN ROSALESFACILITY TYPE:
740
ADDRESS:1106 ROYAL AVENUETELEPHONE:
(805) 210-2757
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 5DATE:
02/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
11:00 AM
MET WITH:Maria Karina AntigTIME VISIT/
INSPECTION COMPLETED:
04:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. Administrator Maria Karina Antig arrived shortly after. LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

LPA inspected the kitchen/food service area at approx. 10:45 a.m.  Knives and sharp objects are stored in a locked cabinet underneath the sink. Some cleaning supplies were observed kept underneath the sink inaccessible to residents in care. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food properly stored at this time. LPA observed medication centrally stored and resident files securely stored in this in a cabinet to the right of the sink.

At the time of the visit, the common area furniture's were observed to be in good condition. A sufficient supply of clean linen and towels were observed stored in the hallways cabinets.  A sufficient supply of PPE and toiletries were observed stored inaccessible to residents in care in a hallway cabinet. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguishers to be fully charged and purchased in December 2024.

LPA observed six (6) bedrooms total. One (1) bedroom is designated for staff use. Resident bedrooms were observed furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are two (2) bathrooms, they were observed to be clean and sanitary and in operating condition with grab bars and non-skid surfaces.  The bathrooms were sufficiently stocked with supplies and paper towels. The hot water temperature was measured between 105 - 120 degrees Fahrenheit. LPA observed staff room to be inaccessible to residents in care  and empty at this time.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/03/2025
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROYAL OAKS HOME CARE
FACILITY NUMBER: 565801851
VISIT DATE: 02/03/2025
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All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common areas. There is an attached garage. LPA observed garage to be inaccessible to residents in care. LPA observed additional fridge and freezer to store extra perishable food.  LPA also observed additional non-perishable supplies and canned goods, extra incontinent supplies, as well as additional furniture and medical equipment for facility use. The backyard has a covered outdoor area equipped with furniture including tables and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted at the time of the visit.
Records review began at approx. 12:05 p.m.  Five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were observed to be in order at this time. At approx 12:40 p.m., Four (4) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. At approx 12:50 p.m. LPA did not observe first aid  / CPR training for Staff #1 (S1) and Staff #2(S2). Last emergency disaster drill was conducted on Jan 18, 2025.

Medications review began at approx. 02:30 p.m. All medications including PRNs were labeled, stored and inaccessible to residents in care. Medications were observed to be administered as prescribed at this time.

Infection control: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has 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 an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the facility’s liability insurance. Interviews were conducted during the visit.
Pursuant to Title 22 of the California Code of Regulations Division 6, Chapter 8, the following deficiencies were cited (refer to LIC 809-D).Failure to correct the deficiencies may result in additional civil penalties.

Exit interview conducted, appeal rights discussed and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/03/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 02/03/2025 03:41 PM - It Cannot Be Edited


Created By: Brian Balisi On 02/03/2025 at 03:19 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: 02/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.618(c)(3)
Other Provisions
(c)The facility shall employ, and the administrator shall schedule, a sufficient number of staff members to do all of the following: (3) Ensure that at least one staff member who has cardiopulmonary resuscitation (CPR) training and first aid training is on duty and on the premises at all times. This paragraph shall not be construed to require staff to provide CPR.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review the licensee did not comply with the section cited above as S1 and S2 did not have current First Aid Certificates on file, which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 02/03/2025
Plan of Correction
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POC cleared during the visit. S1 and S2 provided sufficient first aid certificates during the visit.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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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:Desaree Perera
LICENSING EVALUATOR NAME:Brian Balisi
LICENSING EVALUATOR SIGNATURE:
DATE: 02/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/03/2025


LIC809 (FAS) - (06/04)
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