197609948-5-3-2024-29-AS-MARO-D4WTX5-20240503150633

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609948
Report Date: 05/03/2024
Date Signed: 05/03/2024 03:07:09 PM

Document Has Been Signed on 05/03/2024 03:07 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:	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: 6	DATE:	05/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:40 AM
MET WITH:	Emiliano Siapno		TIME COMPLETED:	03:00 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today. The last annual conducted at this facility was on 05/25/2023. Upon LPA arrival, there were three (3) staff and six (6) residents present. LPA was greeted at the door by staff and the reason for the visit was explained. The Administrator, Emiliano Siapno arrived shortly after. Entrance interview.

At 8:55 a.m., the LPA 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.

KITCHEN: The LPA inspected the kitchen/food service area at 9:00 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Food labels were inspected and checked for dates and expiration dates. The knives and sharps are stored in a locked drawer inaccessible to residents in care. At 9:01 a.m., the hot water temperature was measured in the kitchen sink, and it measured 114 degrees Fahrenheit.

COMMON AREAS: At the time of the visit, the living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 9:13 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguisher was observed to be in compliance and newly purchased on 08/07/2023. The LPA observed required postings throughout the common space.

Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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: ALTA VISTA SIMI, LLC	FACILITY NUMBER: 197609948
	VISIT DATE: 05/03/2024

NARRATIVE

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Continued from LIC 809...

There is a working telephone on premises. There is a separate laundry room with a washer and dryer that was observed locked and inaccessible at the time of the visit. The facility has a sufficient amount of emergency food and water which was observed to be in good condition. The LPA observed a sufficient supply of Personal Protection Equipment (PPE).

BACKYARD: The backyard has a covered outdoor area equipped with furniture for resident use. Emergency exits and passageways were observed free of obstruction. There was one (1) gate that self-latches. No bodies of water were noted at the time of the visit.

BEDROOMS: There are four (4) resident bedrooms. One (1) bedroom is for single occupancy, and three (3) bedrooms are double occupancy. The LPA observed the resident bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting.

RESTROOMS: There are three (3) resident restrooms. The first restroom is located in the hallway, the second restroom is located inside bedroom #6, and third restroom is a jack and jill located between bedrooms #1 and #2. Restrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in all bathrooms. First bathroom measured 112.8 degrees Fahrenheit at 8:57 a.m., the second bathroom measured 113.2 degrees Fahrenheit at 8:59 a.m., and the third bathroom measured 114.1 degrees Fahrenheit at 9:10 a.m.

RECORDS: Records review began at 9:28 a.m.; six (6) resident records were reviewed for, but not limited to: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan.

Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

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: 05/03/2024

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Continued from LIC 809C...

Three (3) personnel records and the current Administrator’s file were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. All files were complete.

The last emergency disaster drill took place on 03/08/2024.

During today’s visit, the LPA obtained copies of the following documents: Personnel Report – LIC 500, Client Roster – LIC 9020, Emergency Disaster Plan – LIC 610E, and current Limited Liability Insurance.

The LPA conducted an interview with one (1) staff member during the inspection.

MEDICATIONS: Medications review began at approximately 12:30 p.m.; medications are centrally stored in a locked cabinet adjacent to the kitchen.

At 12:44 p.m., medications review revealed that Resident #1’s (R1’s) medications Vitamin D3 and Coenzyme Q-10 both filled on 03/22/2024 were started on 05/01/2024; however, were not documented on the Centrally Stored Medication and Destruction Record (CSMDR). Staff documented medications on CSMDR at the time of the visit.

The following deficiency was observed (See LIC 809-D) and cited from the California Code of Regulations, Title 22 and/or California Health and Safety Code.

Exit interview conducted. A copy of the report and appeal rights were provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC809 (FAS) - (06/04)

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Document Has Been Signed on 05/03/2024 03:07 PM - It Cannot Be Edited

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
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 05/03/2024

DEFICIENCIES & PLANS OF CORRECTION (POCs)

Type B

Section Cited

CCR

87465(h)(6)(A-F)

The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: (A) The name of the resident for whom prescribed. (B) The name of the prescribing physician. (C) The drug name, strength and quantity. (D)The date filled. (E) The prescription number and the name of the issuing pharmacy. (F) Instructions, if any, regarding control and custody of the medication. This requirement is not met as evidenced by:
	Deficient Practice Statement
1 2 3 4	Based on LPA observation and medication review, the licensee did not comply with the section cited above as two (2) medications for R1 were not documented on the CSMDR, which poses a potential health, safety or personal rights risk to persons in care.
	POC Due Date: 05/03/2024
	Plan of Correction
1 2 3 4	Staff documented the two (2) missing medications on the CSMDR at the time of the visit. POC has been met.

Section Cited


	Deficient Practice Statement
1 2 3 4
	POC Due Date:
	Plan of Correction
1 2 3 4

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: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 05/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/03/2024

LIC809 (FAS) - (06/04)

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