<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850311
Report Date: 12/15/2025
Date Signed: 12/18/2025 09:03:06 AM

Document Has Been Signed on 12/18/2025 09:03 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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:OMNICARE IIIFACILITY NUMBER:
565850311
ADMINISTRATOR/
DIRECTOR:		VERONA ISAMBIFACILITY TYPE:
740
ADDRESS:1446 SUFFOLK AVENUETELEPHONE:
(818) 274-1809
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
12/15/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:01 AM
MET WITH:Laila Kulungu, Administrator AssistantTIME VISIT/
INSPECTION COMPLETED:
03:30 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a required annual inspection. Upon arrival LPA was greeted by staff and entrance interview and introductions conducted. Assistant Administrator Laila Kulungu was contacted and arrived to the facility.

At approximately 110:15a.m., LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was observed: Fire extinguisher located in the kitchen was observed fully charge with receipt dated 10/2025. There is a functioning telephone on the premises. Emergency exiting plans/sketch are posted. Emergency telephone numbers are posted in the main hallway area wall. Other required postings are also posted on the main hallway area wall. KITCHEN: Kitchen knives are stored in a locked kitchen drawer. The supply of dishes, utensils, pots, pans, and drink ware is adequate. The supply of nonperishable food is adequate. Appliances in the kitchen were clean and all appeared functional. Kitchen, and house cleaning supplies are stored and locked under the sink cabinet area. BEDROOMS: The facility has six (6) private residents’ bedrooms, and one (1) staff’ bedroom. All bedrooms observed with required furniture and clean linen. Lighting in the rooms appeared sufficient. BATHROOMS: There are three (3) bathrooms. Hot water temperature was tested in all restrooms and recorded between 109-118 degrees Fahrenheit. COMMON AREAS: The common areas were appropriately furnished, and the lighting was adequate. Entertainment equipment, books and/or activity supplies observed for residents use. There was sufficient space to accommodate both indoor and outdoor activities. Alarms on all exterior doors were engaged at the time of visit and functional. Garage was observed locked and contained extra food, PPE supplies, cleaning supplies, and water supply. Laundry room observed with supplies and chemicals locked in the cabinets. LPA reviewed the facility emergency disaster and infection control plan with Ms. Kulungu. (Continue to LIC809c)
NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/15/2025
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 5
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)
Page: 2 of 5
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: OMNICARE III
FACILITY NUMBER: 565850311
VISIT DATE: 12/15/2025
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
INFECTION CONTROL: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster drills are conducted quarterly as is required. Earthquake and fire drill conducted on 10/1/2025.

Smoke/carbon monoxide detectors were tested at 11:15am and observed operable. OUTDOOR: The exterior passageways were clean and clear of any obstructions. There is a covered patio with furniture for residents use.



LPA met with all five residents, one family member and two staff. Resident #1 was observed seat belted in a wheelchair. Interview with staff revealed that the family installed the seat belt to prevent resident #1 from falling forward. LPA informed staff that postural devises cannot be used to restrain resident, cannot be used to prevent falls; can only be used to assist in mobility.

RECORD REVIEW: Records review began at 11:30a.m.-1p.m.. LPA observed all five (5) resident records for documents including, but not limited to: needs and service appraisals, medical records, admissions agreement, and consent forms. LPA observed three (3) personnel records for documents including, but not limited to: health assessments, criminal record clearances, first aid/CPR training, and required training. Resident and Personnel files reviewed were in order and had no missing documents.



MEDICATIONS: Medications are stored inaccessible in locked cabinets in the hallway/office area. Beginning at 1:30p.m.-2:30p.m., LPA reviewed five (5) residents medication and medication records. Medications were observed to be properly documented on the centrally stored medications. One out five residents medications reviewed did not have a prescription for over the counter medication (advil/cough syrup).

Pursuant to Title 22, CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D). Administrator was informed that failure to correct deficiencies may result in civil penalties.

Exit interview conducted, report issued, and appeal rights provided.

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 12/15/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/15/2025
LIC809 (FAS) - (06/04)
Page: 3 of 5
Document Has Been Signed on 12/18/2025 09:03 AM - It Cannot Be Edited


Created By: Zabel Chochian On 12/15/2025 at 03:33 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: OMNICARE III
FACILITY NUMBER: 565850311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87608(a)(1)
Postural Supports
(a) Based on the individual's preadmission appraisal, and subsequent changes to that appraisal, the facility shall provide assistance and care for the resident in those activities of daily living which the resident is unable to do for himself/herself. Postural supports may be used under the following conditions: (1) Postural supports shall be limited to appliances or devices such as braces, spring release trays, or soft ties, used to achieve proper body position and balance, to improve a resident's mobility and independent functioning, or to position rather than restrict movement including, but not limited to, preventing a resident from falling out of bed, a chair, etc.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on observation, interview and record review, the licensee did not comply with the section cited above. Resident #1 was observed seat belted in a wheelchair; staff reported that resident falls forward while in the wheelchair and the seat belt is used to prevent fall. This poses an immediate health, safety and personal rights risk to persons in care.
POC Due Date: 12/15/2025
Plan of Correction
1
2
3
4
Administrator and staff stated that they will only use the wheelchair to transfer resident and will not use the seat belt moving forward. Submit plan on how facility plans to keep resident #1 safe and address fall risk. Submit plan by 12/18/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Zabel Chochian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
Page: 4 of 5
Document Has Been Signed on 12/18/2025 09:03 AM - It Cannot Be Edited


Created By: Zabel Chochian On 12/15/2025 at 03:33 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: OMNICARE III
FACILITY NUMBER: 565850311

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 12/15/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87465(e)
Incidental Medical and Dental Care Services
(e) For every prescription and nonprescription PRN medication for which the licensee provides assistance there shall be a signed, dated written order from a physician on a prescription blank, maintained in the resident's file, and a label on the medication. Both the physician's order and the label shall contain at least all of the following information.

This requirement is not met as evidenced by:
Deficient Practice Statement
1
2
3
4
Based on record review and interview with staff, the licensee did not comply with the section cited above. Resident #2 had over the counter medication with out a prescription label for advil and cough syrup. This poses/posed a potential health, safety risk to persons in care.
POC Due Date: 12/18/2025
Plan of Correction
1
2
3
4
Administrator contacted the physician during the visit for an order. Administrator understands they cannot use the medication until they receive the order from the physician. Submit plan of correction by 12/18/2025.
Section Cited
Deficient Practice Statement
1
2
3
4
POC Due Date:
Plan of Correction
1
2
3
4
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:
Zabel Chochian
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 12/15/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 12/15/2025


LIC809 (FAS) - (06/04)
Page: 5 of 5