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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 567609831
Report Date: 10/08/2025
Date Signed: 10/08/2025 03:13:29 PM

Document Has Been Signed on 10/08/2025 03:13 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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ROYAL OAKS INNFACILITY NUMBER:
567609831
ADMINISTRATOR/
DIRECTOR:		JAKOBOVICH, BRANDONFACILITY TYPE:
740
ADDRESS:45 ERBES RDTELEPHONE:
(805) 495-4657
CITY:THOUSAND OAKSSTATE: CAZIP CODE:
91362
CAPACITY: 80CENSUS: 53DATE:
10/08/2025
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Holly GoldTIME VISIT/
INSPECTION COMPLETED:
03:20 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Angela Barutyan and Quoc Huynh arrived at the facility unannounced to conduct a required annual visit at 10AM. Upon arrival, LPAs met with Administrator Holly Gold and explained the reason for the visit. Entrance interview conducted.

Beginning at 10:04AM, the LPAs, along with the Administrator, 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: At 10:04AM, LPAs toured the kitchen. The kitchen is kept inaccessible to residents. Knives and sharps were stored inaccessible to residents. Kitchen appliances were observed to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Emergency food and water supply is stored in a locked storage room.

COMMON AREAS: The common areas include two (2) lounges, two (2) outdoor patios, dining room, activity room, beauty salon, and book nook. LPAs observed required postings throughout the common areas. Common areas were observed to be properly furnished with enough seating to accommodate residents and had a screened fireplace. Fire extinguishers throughout the facility were fully charged and last serviced 05/19/2025. Fire system devices are tested annually by Perfect Connections and were tested 06/10/2025.

BEDROOMS: LPAs inspected five (5) randomly selected bedrooms. Resident bedrooms were observed to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. At 10:17AM, LPAs observed baseboards in room 38 in disrepair. Administrator stated that baseboards will be repaired or replaced. Report Continued on LIC 809.

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE: DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/08/2025
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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Document Has Been Signed on 10/08/2025 03:13 PM - It Cannot Be Edited


Created By: Angela Barutyan On 10/08/2025 at 02:38 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: ROYAL OAKS INN
FACILITY NUMBER: 567609831

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 10/08/2025

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87355(e)
Criminal Record Clearance
(e) All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility:

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 as one (1) staff member did not have a criminal record clearance which poses an immediate health, safety or personal rights risk to persons in care.
POC Due Date: 10/09/2025
Plan of Correction
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Administrator stated that staff will obtain a criminal record clearance and will not be scheduled to work until it is obtained. Administrator will provide proof of criminal record clearance to CCL by the due date.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
Kristin Heffernan
NAME OF LICENSING PROGRAM MANAGER:
Angela Barutyan
NAME OF LICENSING PROGRAM ANALYST:
LICENSING PROGRAM ANALYST SIGNATURE:
DATE: 10/08/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/08/2025


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
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: ROYAL OAKS INN
FACILITY NUMBER: 567609831
VISIT DATE: 10/08/2025
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LPAs observed two (2) rooms with missing window shade panels. Administrator stated that panels will be repaired.

BATHROOMS: Resident bathrooms are shared between rooms with door access from each. Some bedrooms have private bathrooms that are not shared. LPAs observed bathrooms in each resident bedroom to be clean and properly supplied with functional grab bars and fixtures. LPAs observed pull cords by the toilet. Hot water was measured in four (4) bathrooms and were between 108.9-118.8 degrees F, which is within the required range. There are eight (8) shower rooms, however, four (4) are in use. Shower rooms were observed to be clean, sanitary, in operating condition with slip-resistant surfaces, and sufficiently stocked with linens and personal hygiene supplies.

MEDICATION REVIEW: LPAs began medication review at 10:35AM and reviewed medications for three (3) residents. Medications are centrally stored in the medication room by the business office. Medications are prepped up to 24 hours in advance in medication cups. All medications reviewed were stored and documented per regulation.

RECORDS REVIEW: Beginning at 11:08AM, LPAs reviewed five (5) personnel and five (5) residents files for documents including but not limited to: resident Admission Agreement, resident physician’s report, TB test, health screening, staff training and fingerprint clearance. All five resident files reviewed were in compliance with regulation at the time of the visit. LPAs observed one (1) staff member without a criminal record clearance. Administrator stated that the staff member will obtain a criminal record clearance and will not provide care until cleared.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPAs reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Emergency disaster plan is updated annually as required. Emergency disaster drills are conducted quarterly as is required, with the last drill conducted on 07/17/2025.

During today’s visit, LPAs obtained a copy of the facility’s liability insurance.

Pursuant to Title 22, CA Code of Regulations, the following deficiency was cited (refer to LIC 809-D). Civil penalty was issued in the amount of $500 for criminal record clearance. Administrator was informed that failure to correct deficiency may result in additional civil penalties.

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

NAME OF LICENSING PROGRAM MANAGER: Kristin Heffernan
NAME OF LICENSING PROGRAM ANALYST: Angela Barutyan
LICENSING PROGRAM ANALYST SIGNATURE:

DATE: 10/08/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/08/2025
LIC809 (FAS) - (06/04)
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