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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565850313
Report Date: 09/09/2025
Date Signed: 09/16/2025 03:02:17 PM

Document Has Been Signed on 09/16/2025 03:02 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:OMNICAREFACILITY NUMBER:
565850313
ADMINISTRATOR/
DIRECTOR:		KULUNGU, LAILAFACILITY TYPE:
740
ADDRESS:926 CAMINO LA MAIDATELEPHONE:
(818) 274-1809
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 3DATE:
09/09/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:45 AM
MET WITH:Laila KulunguTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility for the purpose of a required annual visit. Upon arrival LPA was greeted by facility staff who contacted the Administrator. The Administrator, Laila Kulunga arrived at approximately 11:30am. Reason for the visit was stated.

At approximately 10:45am, the LPA along with the 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:

KITCHEN: The LPA inspected the kitchen/food service area. Knives and sharps were observed in a locked drawer inaccessible to residents in care. Kitchen appliances observed in operable condition. At least 2-day supply of perishable and 7-day supply of non-perishable food items observed; properly stored. Refrigerator and food pantry were checked for proper storage; items observed labeled and dated. A fire extinguisher observed in the kitchen area with a purchase receipt dated 4/25/2024.

COMMON AREAS: This includes the living room and dining room area. The common areas were furnished appropriately and appeared to be in good condition at the time of the visit. Fireplace made inaccessible. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. LPA observed a hallway closet with resident’s personal hygiene items locked at the time of the visit. Activities observed in the living room. Auditory alarms observed operable at the time of the visit. (Continue to LIC809c)

NAME OF LICENSING PROGRAM MANAGER: Desaree Perera
NAME OF LICENSING PROGRAM ANALYST: Zabel Chochian
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/09/2025
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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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
FACILITY NUMBER: 565850313
VISIT DATE: 09/09/2025
NARRATIVE
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BEDROOMS: There are four (4) bedrooms for resident use; two (2) bedrooms are designated as single occupancy; and two (2) bedrooms are designated as double occupancy. All resident rooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens, towels, and washcloths were observed in the hallway closet. RESTROOMS: The two (2) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Hand washing signs were observed posted inside the bathrooms. The hot water temperature was measured at 118 degrees Fahrenheit in both bathrooms.

GARAGE: The garage is maintained inaccessible to residents in care. LPA observed an additional refrigerator with food in good condition. There is a washer and dryer inside the garage. Cleaning supplies, detergents, and toxins were observed inaccessible to residents in care. Facility has an adequate amount of emergency food and water. LPA observed a sufficient supply of Personal Protection Equipment (PPE). Administrator was reminded to ensure a 30 day supply is maintained at all times. Administrator agreed to inventory current supply and ensure they maintain a 30 day supply. BACKYARD: The backyard has a covered patio area with adequate furniture for resident use. The exterior passageways were clear of any obstructions at the time of the visit. LPA observed two (2) self-latching side gates. There were no bodies of water noted at the time of the visit.



RECORDS REVIEW: Emergency disaster drills conducted quarterly as per regulation; the last drill was conducted on 09/1/2025. LPA reviewed Resident Records at approximately 12:45pm and Personnel Records at 1:15pm. Three (3) resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. Resident #2 and Resident #3 did not have the PRN Authorization letter on file. All files were complete.

Four (4) personnel files including the Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid / CPR training, and the appropriate training. Staff training documentation observed incomplete.

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

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
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
CCLD Regional Office, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: OMNICARE
FACILITY NUMBER: 565850313
VISIT DATE: 09/09/2025
NARRATIVE
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MEDICATIONS: Medications review began at approximately 2:30pm. The medications are locked in cabinet in the kitchen. Resident #1’s (R1’s) is provided assistance with several over the counter medication and vitamins; however, the facility did not have prescription orders on file. Staff obtained copy of doctor’s order / prescription during the inspection. There was no PRN authorization letter on file for resident #2 and resident #3. Administrator obtained the PRN authorization letter during the inspection visit.

The following deficiencies were observed (See LIC 809-D.) and cited from the California Code of Regulations, Title 22 and California Health and Safety Code. Failure to correct the deficiencies may result in civil penalties.

Exit interview conducted. A copy of the report and appeal rights were provided.

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

DATE: 09/09/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/09/2025
LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2025 03:02 PM - It Cannot Be Edited


Created By: Zabel Chochian On 09/09/2025 at 04:25 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
FACILITY NUMBER: 565850313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
CCR
87309(a)
Storage Space and Access
(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on observation, the licensee did not comply with the section cited above. Paint observed stored in the outside storage accessible to residents. This posed a potential health and safety risk to persons in care.
POC Due Date: 09/09/2025
Plan of Correction
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Administrator relocated the paint cans to the locked garage during today's visit.
Type B
Section Cited
CCR
87412(a)
Personnel Records
(a) The licensee shall ensure that personnel records are maintained on the licensee, administrator and each employee. Each personnel record shall contain the following information:

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on record review and interviews, the licensee did not comply with the section cited above as staff #4 training was incomplete; and unable to verify training dates, duration and time; this poses a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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The Licensee or Administrator agree to have staff #4 complete training and provide proof to CCL on or before POC due date.
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: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/16/2025 03:02 PM - It Cannot Be Edited


Created By: Zabel Chochian On 09/09/2025 at 04:25 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
FACILITY NUMBER: 565850313

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/09/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type B
Section Cited
HSC
1569.69(a)(2)
Other Provisions
(a) Each residential care facility for the elderly licensed under this chapter shall ensure that each employee of the facility who assists residents with the self-administration of medications meets all of the following training requirements: (2) In facilities licensed to provide care for 15 or fewer persons, the employee shall complete 10 hours of initial training. This training shall consist of 6 hours of hands-on shadowing training, which shall be completed prior to assisting with the self-administration of medications, and 4 hours of other training or instruction, as described in subdivision (f), which shall be completed within the first two weeks of employment.

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. Unable to verify/confirm medication training for staff #4. This poses/posed a potential health, safety or personal rights risk to persons in care.
POC Due Date: 09/23/2025
Plan of Correction
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Licensee/Administrator stated they will have a skilled professional provide shadowing and medication training for staff #4.
Submit proof of training by 9/23/2025.
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
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Based on observation, interview and record review, the licensee did not comply with the section cited above. Administrator did not have doctor's order/prescription for several OTC and PRN medications for R1. This poses a potential health, safety or personal rights risk to persons in care.

POC Due Date: 09/10/2025
Plan of Correction
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Staff obtained doctor's order/prescription for R1's PRN and OTC medication/vitamins.
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: 09/09/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/09/2025


LIC809 (FAS) - (06/04)
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