<meta name="robots" content="noindex">
Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802115
Report Date: 10/18/2024
Date Signed: 10/18/2024 01:50:13 PM

Document Has Been Signed on 10/18/2024 01:50 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 NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:SIMMONS RESIDENTIAL CAREFACILITY NUMBER:
425802115
ADMINISTRATOR/
DIRECTOR:		SYLIVA SOLORIOFACILITY TYPE:
735
ADDRESS:505 SAINT ANDREW WAYTELEPHONE:
(805) 733-0112
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 4CENSUS: 3DATE:
10/18/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
10:00 AM
MET WITH:Nancy Solorio, Assistant AdministratorTIME VISIT/
INSPECTION COMPLETED:
02:00 PM
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
On 10/18/2024, Licensing Program Analyst (LPA) Brian Phillips arrived at the facility above to conduct an unscheduled, required inspection evaluation visit. When the LPA arrived, they were greeted by Assistant Administrator Nancy Solorio and informed them of the reason for the visit.

The LPA 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. This is an Adult Residential Facility (ARF) approved for four (4) ambulatory clients only.

The LPA inspected the food service area and observed that knives/sharp instruments are stored appropriately as per the type of facility and clients in care. All appliances were in operable condition and looked clean/in good repair. Appliances such as microwaves, refrigerators, stoves, etc. are clean and operating properly. Food utensils, dishes, glasses, etc. are clean and in good repair with no cracks or chips. Furniture is room/client appropriate, clean and in good repair. All rooms are appropriately furnished for their intended use such as bedrooms, dining rooms, kitchens, living rooms, etc. Hot water temperature is maintained between 105-120 degrees Fahrenheit as per Community Care Licensing (CCL) Title 22 regulations. Outdoor activity spaces have shaded areas and furnished for outdoor use. Each client has an adult bed with a mattress, pad, bedsprings, and pillow, which are clean and in good repair. Each bed is fitted with sheets, pillowcase, blankets, and bedspread that are clean and in good repair. Each client has adequate dresser and closet space for clothing and other belongings that includes at least two drawers or adequate dresser space. The facility has a sufficient supply of linens to permit weekly changing or more often to always insure clean linens for clients. Equipment and supplies for client personal hygiene is available and on site. Activity supplies are available for clients. As the facility has an approved fire clearance for a maximum of four (4) clients, there is no signal system required or observed by LPA. Refrigerators and freezers are maintained at an appropriate temperature Fahrenheit as per Community Care Licensing (CCL) regulations. Food storage and preparation areas, including pantries, cupboards, counters, etc., are clean and appropriate for food preparation. The food service area was clean and sanitary, with covered trashcans and operating ventilation systems. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE: DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 10/18/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SIMMONS RESIDENTIAL CARE
FACILITY NUMBER: 425802115
VISIT DATE: 10/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
No toxic substances are stored in any food preparation or storage area, and all cleaning supplies for the kitchen are kept in a separate area than the food supplies. There is enough tableware and utensils for all clients living in the facility, and enough equipment for the storage, preparation, and service of food. A locked storage area for central storage of medications is available. Cleaning supplies are kept in areas separate from where food supplies are stored. Walls, ceilings, floors, carpeting, window screens, and areas around the facility are clean, painted and/or in good repair. There are locked storage area(s) for poisons, toxic, cleaning solutions, disinfectants, etc. Smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were fully charged and are serviced annually. Doors and passageways are unobstructed. There are no pools/bodies of water on the physical plant of the facility as observed by LPA. During the inspection, LPA did not observe any firearms that would require trigger locks, locked and inaccessible, or firing pins removed.

At the time of the visit, all common areas/interior rooms of the facility were observed to be appropriately furnished, with all furniture in good condition. There is a fireplace in the living room, which is covered and inaccessible to clients. The facility is a two (2) story home that has client bedrooms upstairs. However, the facility is only licensed for ambulatory clients and the staircase has sturdy handrails for support. The LPA observed required postings throughout the common spaces including Client Personal Rights and Contact information for Ombudsman as well as Licensing. There are activity materials in the common areas of the facility in good repair and operating condition. The facility maintained a comfortable temperature in all areas inspected. There is appropriate lighting in all the common areas of the facility. All passageways through the common areas of the facility were free of obstruction, and all changes in incline are well lit with sturdy hand railings/stair chair accessibility devices. Clients must utilize an indoor staircase, but the facility is only licensed for ambulatory clients. There are no bodies of water as observed by LPA on the physical plant of the facility. LPA did not observe any noticeable outdoor hazards in the front or backyard of the facility. The backyard of the facility consists of concrete steps and an open porch with tables and chairs. The front of the facility is separated from the backyard by fence with a gate that remains unlocked. The recycling bin, green waste bin, and trash bins are standard bins with flip lids. Outdoor activity spaces are completely enclosed by a fence and gates or walls. Outdoor activity spaces are equipped with furniture for client use including a patio with an umbrella for shade. All outdoor areas with stairways, inclines, ramps, or open porches have accessibility ramps for clients, and are well-lit. There were no bodies of water noted. A garage is located off the kitchen/living room of the facility and contains additional supplies/emergency supplies. The laundry room is accessible through the common area of the facility as an addendum to the kitchen area. Contd. 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
Page: 2 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SIMMONS RESIDENTIAL CARE
FACILITY NUMBER: 425802115
VISIT DATE: 10/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The designated laundry area in the facility has an attached bathroom and is where cleaning products are stored, which are kept locked and inaccessible to clients. Emergency food and water in storage area of the garage which was observed to be in good condition. Cleaning supplies, disinfectants, and other items that could pose a danger to clients are kept in areas inaccessible to clients. As the facility is licensed for a maximum of four (4) clients total, there is no signal system in place. There is a Staff bedroom on the 1st floor of the facility that contains a desk, computer, chair, and bed with furniture. The 1st floor of the facility has a locked cabinet within a storage area where the Centrally Stored Medications are kept locked and inaccessible to clients. The vehicles used to transport clients are in safe operating condition with appropriate insurance information. There is a storage room next to the garage of the facility which contains tools, gardening supplies, and maintenance materials that was inspected by the LPA.

The facility restrooms were sanitized and in operating condition while the LPA toured the facility. All restrooms in the facility were sufficiently stocked with soap, paper towels, required postings, and clean trashcans with closed lids. Towels and washcloths are not shared by clients in the facility. The hot water temperature was measured in the restrooms at the appropriate degrees Fahrenheit as per Title 22 regulations between 105-120 degrees Fahrenheit. There are an adequate number of toilets per clients in the facility. Nightlights are installed as observed by LPA. All toilets and hand washing areas are maintained in safe and sanitary operating condition. Additional equipment, aids, and/or conveniences are available accommodate any physically handicapped clients who need such items. The LPA observed the client bedrooms, which were furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. Each client bedroom has a bed, nightstands, and lights and nightstand lamps to provide sufficient lighting. Each closet in all the client rooms can store or has extra pillows, clean/fresh linens, and appropriate incontinence materials if applicable for any client. The client bedrooms are big enough for all beds, furniture, and any client assisting device a client might need such as a wheelchair or a walker. Each room has sufficient lighting for each client. The facility has provisioned to each client of furniture, equipment and supplies necessary for personal care and maintenance of personal hygiene. An emergency exiting plan and emergency phone numbers are posted in an appropriate place. A current disaster and mass casualty plan maintained at the facility. The facility’s policies and procedures as it pertains to infection control are adequate. First-aid supplies, which include sterile first-aid dressings, bandages, adhesive tapes, scissors, tweezers, thermometer, antiseptic solution, and a current first-aid manual, are maintained. Administrator’s records, employees and client records are maintained at the facility and available for review by the LPA as employees are hired and clients accepted into the facility. Continued on 809-C

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
Page: 3 of 4
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS NORTH, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME: SIMMONS RESIDENTIAL CARE
FACILITY NUMBER: 425802115
VISIT DATE: 10/18/2024
NARRATIVE
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
The facility complies with CCL standards for health screening, TB clearance, staff training, criminal background clearance and transfer requests. Admission agreements and needs and services (ANS) plan are maintained for each client and/or their authorized representative. Client records are maintained on the facility premises in a secured area. Centrally stored medications are locked in secure locked cabinet(s) inaccessible to clients. The LPA observed the centrally stored medications as well as the Centrally Stored Medication and Destruction Record. LPA audited the medications for residents and noticed no irregularities or issues concerning the dispensing of medications or the logging of medications. The medications in the facility were labeled appropriately with no prohibited marking by the facility. The facility administrator meets the qualifications as specified in Title 22 regulations. There are required postings throughout the facility, including emergency exit plans with necessary telephone numbers. Provider Information Notices are available and able to be presented to Staff, clients, visitors, and accessible to LPA upon request during the inspection process.

Exit interview conducted by LPA. Copy of this report provided to the facility.

SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Brian Phillips
LICENSING EVALUATOR SIGNATURE:

DATE: 10/18/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 10/18/2024
LIC809 (FAS) - (06/04)
Page: 4 of 4