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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609762
Report Date: 06/21/2021
Date Signed: 06/21/2021 11:48:50 AM

Document Has Been Signed on 06/21/2021 11:48 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:ENDURING OAKS ASSISTED LIVING THOUSAND OAKSFACILITY NUMBER:
567609762
ADMINISTRATOR:YACOUB, MIRVATFACILITY TYPE:
740
ADDRESS:952 E JANSS RDTELEPHONE:
(805) 852-5130
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91360
CAPACITY: 6CENSUS: 5DATE:
06/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:YACOUB, MIRVATTIME COMPLETED:
12:00 PM
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Licensing Program Analysts (LPAs) Martha Guzman-Chavez and Brian Balisi conducted an unnounced visit to conduct a Required Annual inspection with a focus on Infection Control. LPAs met with Mirvat Yacoub and explained the reason for the visit.

At 10:05 the LPAs began the physical plant tour of the common areas, kitchen area, resident bedrooms, staff room, bathrooms, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

LPAs observed a sufficient supply of perishable and non-perishable foods and dried goods stored in the pantry. Emergency food supply was stored in the garage. LPA did not observe any cleaning supplies stored in the kitchen. LPAs observed sharp objects and knives were stored in a locked drawer to the left of the oven. Medications were stored in locked cabinet in the living room.



The common areas were appropriately furnished, and lighting was adequate at the time of the visit. At 10:08am LPAs observed 4 residents sitting in living room watching television.

Bedrooms were observed to have adequate furniture such as a bed, 2 night stands, a drawer, and a television.

Continued on 809-C
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE: DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 06/21/2021
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: ENDURING OAKS ASSISTED LIVING THOUSAND OAKS
FACILITY NUMBER: 567609762
VISIT DATE: 06/21/2021
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Continued from 809

Between 10:08-11:30am LPAs did not observe a sufficient amount of the following: 30 day supply of PPE.
Mirvat also informed LPAs that not all staff have been fit tested for N95 respirators.

LPAs advised Mirvat to obtain a 30 day supply of PPE and LPAs will also provide Mirvat with information and resources to have all staff fit tested for N95 respirators.

Pursuant to Title 22, Division 6, facility observed to be compliant with regulation. No corrections needed at this time. Exit interview was conducted with Mirvat and a hard copy was issued via email.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Guzman-Chavez
LICENSING EVALUATOR SIGNATURE:

DATE: 06/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/21/2021
LIC809 (FAS) - (06/04)
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