197609948-8-25-2023-29-AS-ZCHN-CS73LA-20230525182025

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 197609948
Report Date: 05/25/2023
Date Signed: 08/25/2023 04:41:39 PM

Document Has Been Signed on 08/25/2023 04:41 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:	05/25/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	12:42 PM
MET WITH:	Emiliano Siapno		TIME COMPLETED:	05:45 PM

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Licensing Program Analyst (LPA) Zabel Chochian conducted a required annual visit. Upon arrival LPA met with staff and reason for visit was explained. Staff contacted Administrator who arrival at approximately (approx.) 1:45pm. Reason for visit was explained to Administrator Emil Siapno.

The LPA conducted a toured of the physical plant areas (inside and out) with staff at approx. 1pm, to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. KITCHEN: Knives and sharp objects are stored in a locked cabinet in the kitchen. Cleaning supplies are stored locked and inaccessible to residents. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms were fully stocked with soap and paper towels. Appropriate hand-washing signs were observed the bathrooms. Hot water temperature tested within required range (114*f). COMMON SPACES: Living room and dining room furniture was observed to be in good condition. All exits have functioning auditory devices. The LPA observed the required licensing postings listed throughout the facility.

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 locked. Washer and dryer are located in garage, including an additional refrigerator. The LPA observed an adequate supply of Personal Protection Equipment (PPE) stored in the garage and the facility is able to obtain additional supplies as needed.

There is a new shed built in the backyard which is used as an office/staff break room.

Staff and resident records reviewed at approximately 2pm-3:30pm. Staff records reviewed for current first aid certification, health screening documentation, criminal record clearance and other training. Staff files are current with required documents and training.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

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: ALTA VISTA SIMI, LLC	FACILITY NUMBER: 197609948
	VISIT DATE: 05/25/2023

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Residents’ records reviewed for updated Needs and Services plans, medical assessments, admission agreements, and all other pertinent documents in their file.

Medications observed in a locked filing cabinet next to the dining table in the kitchen. Random sample of resident medications and records reviewed from approx. 3:30pm-4:30pm. First aid kit observed complete with manual at approx. 4:45pm. At approx. 5pm, LPA reviewed a binder which included the facility Emergency Disaster plan however it was incomplete. Administrator downloaded the LIC610E (3/19) form to complete for use moving forward.

Facility observed to be in substantial compliance during todays visit.

Exit interview conducted. Copy of report provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel Chochian	TELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:	DATE: 05/25/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 05/25/2023

LIC809 (FAS) - (06/04)

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