197609948-5-18-2021-29-AS-ASMH-C35PYK-20210518114405

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609948
Report Date: 05/18/2021
Date Signed: 05/18/2021 11:45:28 AM

Document Has Been Signed on 05/18/2021 11:45 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:	ALTA VISTA SIMI, LLC		FACILITY NUMBER:	197609948
ADMINISTRATOR:	SIAPNO, EMILIANO		FACILITY TYPE:	740
ADDRESS:	2624 RUDOLPH DRIVE		TELEPHONE:	(760) 613-6480
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY: 6		CENSUS: 5	DATE:	05/18/2021
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:10 AM
MET WITH:	Emil Siapno		TIME COMPLETED:	11:45 AM

NARRATIVE

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Licensing Program Analysts (LPAs) Ashley Smith and Salia Walker arrived at the facility unannounced to conduct a required annual visit at 9:15am. This annual had a specific emphasis on infection control practices and procedures. The LPA met with Administrator Emil Siapno and explained the reason for the visit.

The LPAs 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.

KITCHEN: Knives are stored in a locked cabinet in the kitchen. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food.

BEDROOMS: The LPAs observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Each resident has a private room.

RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. The LPAs advised the Administrators to ensure that bathrooms were stocked with paper towels and hand-washing signs. At 9:28am, the LPAs observed accessible razors in the bathroom cabinet.

COMMON SPACES: In the common areas, walls and flooring were checked for cleanliness and good condition. At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPAs observed the required postings in the hallway. At 9:31am, the laundry room was unlocked, and there were accessible laundry supplies. The Administrator secured it at the time of observation.

The backyard has a covered outdoor area equipped with furniture for resident use. The side gate door is self-latching. There were no bodies of water noted. The garage is where the washer and dryer are held, including additional nonperishable and perishable food items. The garage is attached to the facility; however, at 9:27am it was observed to be unlocked. At the time of observation, the cleaning supplies in the garage were accessible. The Administrator secured it at the time of observation.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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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Document Has Been Signed on 05/18/2021 11:45 AM - It Cannot Be Edited

Created By: Ashley Smith On 05/18/2021 at 10:58 AM

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: ALTA VISTA SIMI, LLC	FACILITY NUMBER: 197609948
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/18/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type A

Section Cited

CCR

87705(f)(1)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (1) Knives, matches, firearms, tools and other items that could constitute a danger to the resident(s). This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as razors were observed to be accessible in the bathroom, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 05/18/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. Lock up the razors. This was done during today's visit. Plan of Correction met.

Type A

Section Cited

CCR

87705(f)(2)

Care of Persons with Dementia

(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on observation, the licensee did not comply with the section cited above, as there were accessible cleaning supplies and over-the-coutner medications observed, which poses an immediate health and safety risk to residents in care.
	POC Due Date: 05/18/2021
	Plan of Correction
1 2 3 4	The Administrator has agreed to do the following: 1. Lock up the cleaning supplies and medications. This was done during today's visit. Plan of Correction met.

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISOR'S NAME:

Jeralyn Ann Pfannenstiel

LICENSING EVALUATOR NAME:

Ashley Smith

LICENSING EVALUATOR SIGNATURE:

DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

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: ALTA VISTA SIMI, LLC	FACILITY NUMBER: 197609948
	VISIT DATE: 05/18/2021

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INFECTION CONTROL: During today’s visit, the LPAs spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPAs observed 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 facility does not have a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate. The following recommendations were made:

- Testing Protocol, to ensure that 25% of staff are being tested weekly

- Appropriate signage to remind staff and residents of cough etiquette, visitation policies and procedures, hand hygiene, etc.

- Posting Provider Information Notices (PINs) and educating staff, residents, and families on changing policies and procedures from the Department

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.

SUPERVISORS NAME: Jeralyn Ann Pfannenstiel
LICENSING EVALUATOR NAME: Ashley Smith
LICENSING EVALUATOR SIGNATURE:	DATE: 05/18/2021

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/18/2021

LIC809 (FAS) - (06/04)

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