567609762-7-25-2023-29-AS-ECAS-CU3VSY-20230725164220

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609762
Report Date: 07/25/2023
Date Signed: 07/25/2023 04:42:53 PM

Document Has Been Signed on 07/25/2023 04:42 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:	ENDURING OAKS ASSISTED LIVING THOUSAND OAKS		FACILITY NUMBER:	567609762
ADMINISTRATOR:	YACOUB, MIRVAT		FACILITY TYPE:	740
ADDRESS:	952 E JANSS RD		TELEPHONE:	(805) 852-5130
CITY:	THOUSAND OAKS	STATE: CA	ZIP CODE:	91360
CAPACITY: 6		CENSUS: 6	DATE:	07/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:10 PM
MET WITH:	Administrator-Mirvat Yacoub		TIME COMPLETED:	04:50 PM

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Licensing Program Analyst (LPA) Elsie Campos arrived at the facility unannounced to conduct a required annual visit at 1:10 p.m. The LPA was greeted by staff and informed them of the reason for the visit. Administrator Mirvat Yacoub arrived shortly thereafter.

The LPA and the staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations.

KITCHEN: The LPA began the inspection in the kitchen/food service area at 1:25 p.m. the kitchen was observed to be clean and sanitary. Knives and cleaning supplies are stored inaccessible. Kitchen appliances were in operable condition. The facility had a sufficient supply of two-day perishable and seven-day nonperishable food.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. There is a fireplace in the living room, which is screened and inaccessible. The facility maintained a comfortable temperature of 74 degrees. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The LPA observed fire extinguishers throughout the facility which were last serviced 04/15/2023. LPA observed required postings throughout the common space. There is a laundry room where cleaning supplies and disinfectants are kept locked in cabinets. The garage is attached and locked. The garage keeps emergency food supplies, water and Personal Protection Equipment (PPE). It is additionally used as an office.

OUTDOOR AREA: The backyard has a covered outdoor area equipped with furniture for client use. There is a side gate for client use and is single latched. No bodies of water noted and exits are free of obstructions.

BEDROOMS: Bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are five (5) designated resident bedrooms and two (2) staff rooms.

**Continued on LIC 809-C**

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

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: 07/25/2023

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RESTROOMS: There are five (5) resident restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature in bathrooms measured between 108.6-111.3 degrees Fahrenheit.

RECORD REVIEW: At 2:00 p.m. a review of facility files was initiated. The LPA observed documentation of Infection Control, Disaster prevention, and liability Insurance. The LPA obtained Client Roster, Staff Roster, and Liability Insurance.

Residents’ records review began at 2:15 p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

Personnel records were reviewed for, but not limited to health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were in order.

MEDICATIONS: Medications review began at 3:05 p.m.; medications are centrally stored and locked in a mediation cabinet in the dining room; medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. 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 COVID-19.

The LPA obtained the following documents:

- LIC500 Personnel Report
- LIC9020 Client Roster
- Liability Insurance

No deficiencies cited at this time. Exit interview conducted. A copy of the report was issued.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Elsie Campos
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2023

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2023

LIC809 (FAS) - (06/04)

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