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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850108
Report Date: 06/03/2025
Date Signed: 06/04/2025 08:27:06 AM

Document Has Been Signed on 06/04/2025 08:27 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:OAK PLACE RESIDENTIAL CAREFACILITY NUMBER:
565850108
ADMINISTRATOR/
DIRECTOR:		SPRING, BECKYFACILITY TYPE:
740
ADDRESS:50 OAK ST.TELEPHONE:
(805) 586-4086
CITY:CAMARILLOSTATE: CAZIP CODE:
93010
CAPACITY: 36CENSUS: 35DATE:
06/03/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
09:20 AM
MET WITH:Flordeliza "Baby" Hipolito TIME VISIT/
INSPECTION COMPLETED:
03:45 PM
NARRATIVE
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Licensing Program Analyst (LPA) Valeria Conway arrived at the facility unannounced to conduct a required annual visit. LPA met with facility administrator, Flordeliza “Baby” Hipolito, and explained the reason for today’s visit. Entrance interview conducted.

At 10:00 A.M. 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. This facility is a two-story building. On the ground floor, this facility has twelve (12) rooms and two full and three half (2 full and 3 ½) bathrooms. The second floor contains eight (8) rooms and two and a one half (2 full and 1 ½) bathrooms. This facility doesn’t have a staff room, facility will provide 24/7 care. The following was observed.

BEDROOMS: Resident bedrooms appeared to be furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are twenty total bedrooms, all of which were observed during the facility tour; four are private resident rooms and sixteen are shared resident rooms. Carbon monoxide detectors were observed in each room; randomly chosen detectors were tested and functioned properly.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. LPA observed sufficient amounts of soap and paper products in each restroom. Between 10:10 A.M. and 10:45 A.M. hot water temperature was tested in a sampling of resident restrooms, which was measured at 112.2 – 117.4 degrees Fahrenheit, which is within the required range.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/03/2025
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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California Health & Human Services Agency
California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:
  • Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.
  • Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)
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Document Has Been Signed on 06/04/2025 08:27 AM - It Cannot Be Edited


Created By: Valeria Conway On 06/03/2025 at 03:01 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: OAK PLACE RESIDENTIAL CARE
FACILITY NUMBER: 565850108

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/03/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.695(e)(3)
Other Provisions
(e) A facility shall have all of the following information readily available to facility staff during an emergency: (3) A resident medication list for residents with centrally stored medications.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation and record review, the licensee did not comply with the section cited above by not having a current medication list for multiple residents which poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 06/10/2025
Plan of Correction
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Staff in charge of the medication room and storage of medication will audit the centrally stored medication log and update it. Facility administrator will have an in-service training will all staff in charge of medication documentation and submit to LPA before POC due date.
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.
Desaree Perera
NAME OF LICENSING PROGRAM MANAGER:
Valeria Conway
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 06/03/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/03/2025


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: OAK PLACE RESIDENTIAL CARE
FACILITY NUMBER: 565850108
VISIT DATE: 06/03/2025
NARRATIVE
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Continued from LIC 809

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, common seating areas and dining room furniture were observed to be in good condition. The LPA observed the required postings in the common hallway. The temperature inside the facility was maintained at a comfortable level throughout today's visit. The LPA observed cameras in the common areas. A working telephone is present. Fire extinguishers were observed to be fully charged and last serviced on 8/27/2024. Fire inspections are conducted annually by Integrated Fire Safety (IFS). The last inspection was conducted on 7/17/2024. IFS also conducted the facility's five-year inspection of the fire sprinkler system on 2/9/2023 with no concerns noted.

KITCHEN: LPA observed the kitchen/dining area. Kitchen appliances appear to be in operable condition. LPA observed at least 2-days of perishable and at least 7-days of nonperishable foods, including emergency supply and water. Cook stated that the facility uses Sysco for their food supply and delivery takes place every Tuesday. All knives and cleaning supplies were observed to be locked and stored in compliance with regulation.

OUTDOOR SPACE: The outdoor area has two covered outdoor seating areas equipped with furniture for residents' use. An outdoor space is designated for smoking. There were no bodies of water observed.

RECORD REVIEW: Between 11:30 A.M. and 1:35 P.M. LPA reviewed staff and resident records for documents including, but not limited to: health screening, TB test, staff training records, fingerprint clearance, resident physician's report, needs and service appraisals, and admission agreements. The seven (7) staff files reviewed contained all documents. Separate training binder is maintained for all staff training. All nine (9) residents' files reviewed were missing consent for emergency medical treatment form (LIC627C), technical violation issued (TV). All other necessary forms were in compliance. Additionally, LPA observed that the Emergency Disaster Plan and the Infection Control Plan had not been updated with the required annual signatures. The Administrator reviewed and updated both plans during today’s visit. Technical violation issued. Last emergency drill was conducted on 04/30/2025.

Continued on LIC 809-C

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
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: OAK PLACE RESIDENTIAL CARE
FACILITY NUMBER: 565850108
VISIT DATE: 06/03/2025
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Continued from LIC 809-C

MEDICATION REVIEW: Medication is kept locked in the medication room on the ground floor. At 1:50 P.M. LPA reviewed medications for five (5) randomly chosen residents. All medications appeared to be given as prescribed, however, three (3) resident’s medication list with current centrally stored medication were missing.

INTERVIEWS: LPA interviewed two (2) staff and two (2) residents; no concerns were noted.

Pursuant to Title 22, California Code of Regulations and/or CA Health and Safety Code, the following deficiencies were cited (refer to LIC 9099-D.) Administrator was informed that failure to correct the deficiencies may result in civil penalties.

Exit interview conducted, appeal rights discussed, and a copy of this report and appeal rights were provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Valeria Conway
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 06/03/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/03/2025
LIC809 (FAS) - (06/04)
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