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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198204374
Report Date: 09/14/2021
Date Signed: 09/14/2021 03:36:02 PM

Document Has Been Signed on 09/14/2021 03:36 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, 1000 CORPORATE CNTR DR. ST 500
MONTEREY PARK, CA 91754
FACILITY NAME:SIMLA VILLAS INC.FACILITY NUMBER:
198204374
ADMINISTRATOR:SIMLA MEHTAFACILITY TYPE:
740
ADDRESS:16623 ARDMORE AVENUETELEPHONE:
(562) 804-3603
CITY:BELLFLOWERSTATE: CAZIP CODE:
90706
CAPACITY: 15CENSUS: 11DATE:
09/14/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:15 PM
MET WITH:Dhananjana Franklin, House ManagerTIME COMPLETED:
03:45 PM
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Licensing Program Analyst (LPA) Cynthia Chan conducted the annual required inspection using the infection control tool. LPA arrived unannounced and met with Dhananjana Franklin, House Manager/Caregiver. The reason for the visit was explained. The Administrator, Simla Mehta, and Co-Administrator, Jennifer Bobadilla arrived later to assist with the visit. The Administrator Mehta's certificate expires on 11/13/2023.

The facility is licensed to serve (15) residents, ages 60 and above, 11 may be non-ambulatory and 4 bedridden. The facility has an approved hospice waiver for (4) residents.

At 1:35 p.m., LPA Chan and the House Manager toured the facility and observed/inspected the following:
* There are 9 resident rooms and 3 bathrooms for resident use. Each bedroom is equipped with the proper furnishings. There is one bedroom and one bathroom for the live-in caregivers.
* Signage are posted throughout the facility to promote hand hygiene.
* Upon entry, routine symptoms screening is taken and documented. There is a designated outdoor area for visitation.
* The hot water temperature was measured within the range of 105 -120 degree F.
* Medications were reviewed for 5 residents and are being administered as prescribed.
* Staff indicated they are cleaning and disinfecting the facility multiple times a day, including mopping the floors.
* Staff were all wearing face coverings.
* Cleaning supplies and disinfectants were locked and stored away, inaccessible to residents.
* Adequate supplies of 2 day perishable and a week of non-perishable foods were observed. Extra food supplies are stored in the garage storage room.

There are no deficiencies observed during today's visit. An exit interview was conducted and a copy of this report along with the appeal rights were given to the Administrator.
SUPERVISORS NAME: Lisa Hicks
LICENSING EVALUATOR NAME: Cynthia D Chan
LICENSING EVALUATOR SIGNATURE: DATE: 09/14/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/14/2021
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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