567609762-7-25-2024-29-AS-ZCHN-D7HUVH-20240725155510

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 567609762
Report Date: 07/23/2024
Date Signed: 07/25/2024 03:57:19 PM

Document Has Been Signed on 07/25/2024 03:57 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/ DIRECTOR:	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: 5	DATE:	07/23/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	11:00 AM
MET WITH:	Tammy Frame, Assistant Administrator		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a required annual visit. The LPA met with staff and reason for visit was stated. Assistant Administrator arrived shortly after.

At approximately 11:15 a.m., the LPA, staff and Assistant Administrator 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. 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 04/15/2024. 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 (converted into office space) is attached to the home and therefore kept locked/inaccessible to others. Emergency food supplies, water and Personal Protection Equipment is stored in the garage/office space.

BEDROOMS: Bedrooms observed furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. There are five (5) designated resident bedrooms and two (2) staff rooms. RESTROOMS: There are five (5) resident restrooms. Restrooms observed 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 115-117 degrees Fahrenheit.

KITCHEN: 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.

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.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

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: 07/23/2024

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RECORD REVIEW: Residents’ records review began at 12p.m., records were reviewed for, but not limited to care plans, medical records, admissions agreement, consent forms. All records were in order.

At approximately 12;45p.m., Staff 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 1:30p.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.

The LPA requested following documents to be faxed to the Regional Office:

- LIC500 Personnel Report
- Liability Insurance

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

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Zabel Chochian
LICENSING EVALUATOR SIGNATURE:	DATE: 07/23/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/23/2024

LIC809 (FAS) - (06/04)

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