425802115-4-2-2025-29-AS-GHTO-DFCQTS-20250402122737

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 425802115
Report Date: 04/02/2025
Date Signed: 04/02/2025 12:27:52 PM

Document Has Been Signed on 04/02/2025 12:27 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 N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME:	SIMMONS RESIDENTIAL CARE		FACILITY NUMBER:	425802115
ADMINISTRATOR/ DIRECTOR:	ANTHONY SIMMONS		FACILITY TYPE:	735
ADDRESS:	505 SAINT ANDREW WAY		TELEPHONE:	(805) 733-0112
CITY:	LOMPOC	STATE: CA	ZIP CODE:	93436
CAPACITY: 4		CENSUS: 3	DATE:	04/02/2025
TYPE OF VISIT:	Case Management - Incident	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	10:00 AM
MET WITH:	Licensee/Administrator Anthony Simmons		TIME VISIT/ INSPECTION COMPLETED:	12:45 PM

NARRATIVE

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Licensing Program Analyst (LPA) Haner-Tomasko and Licensing Program Manager (LPM) Kelly Burley conducted an unannounced Case Management visit. LPA and LPM arrived at the facility, met with Licensee/Administrator Anthony Simmons, and announced the purpose of the visit.

On 3/20/2025, the Administrator submitted an Incident Report (SIR) where Client 1 (C1) disclosed Staff 2 (S2) blew in their ear and jumped in C1’s bed while C1 was sleeping. C1 stated they elbowed S2 to get them out of the bed. C1 indicated the incident happened before December 2024. During an interview, C1 stated similar information to licensing staff, but details were different, including what C1 was wearing when the incident occurred. When interviewed by licensing staff, C1 stated they were not afraid and felt safe, and stated no inappropriate touching occurred. Per the SIR, C1 was questioned by Tri-Counties Regional Center staff about why they did not bring up this incident at prior meetings, but C1 did not have an explanation. Per the SIR, Administrator also pointed out that C1 has been talking on the phone with former staff S1, who was terminated from the facility for their conduct, and noted that S1 and S2 did not get along. Administrator also noted in SIR multiple occasions where C1 changed their story on other topics.

LPA interviewed S2 and clients in the facility. S2 denied ever going into C1’s bed. S2 denied acting inappropriately with any clients in the home. Clients interviewed indicated they have not heard of or experienced any inappropriate behavior from staff.

No deficiencies were issued during this visit. The LPA may return at a later date if it is determined deficiencies are warranted.

Exit interview, report given.

NAME OF LICENSING PROGRAM MANAGER: Kelly Burley
NAME OF LICENSING PROGRAM ANALYST: Garrett Haner-Tomasko
LICENSING PROGRAM ANALYST SIGNATURE:	DATE: 04/02/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 04/02/2025

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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California Health & Human Services Agency

California Department of Social Services

FACILITY EVALUATION REPORT California law requires a public report of each licensing visit/inspection. This report is a record for the facility and the licensing agency. This report is available for public review; therefore, care is taken not to disclose personal or confidential information. Inquiries concerning the location, maintenance, and contents of these reports may be directed to the Licensing Program Analyst or Regional Office whose address and telephone number are listed on the front of this form.

DEFICIENCIES A deficiency is an instance of noncompliance with licensing requirements, including applicable statutes, regulations, interim licensing standards, operating standards, and written directives. Applicants/ licensees must be notified in writing of all licensing deficiencies. Deficiencies are listed on the left side of this form, and the applicable licensing requirement upon which the deficiency is identified. There are two types of deficiencies:

Type A deficiencies are violations of licensing requirements that, if not corrected, have a direct and immediate risk to the health, safety, or personal rights of persons in care.

Type B deficiencies are violations of licensing requirements that, without correction, could become a risk to the health, safety, or personal rights of persons in care, a recordkeeping violation that could impact the care of said persons and/or protection of their resources, or a violation that could impact those services required to meet the needs of persons in care.

PLANS OF CORRECTION (POCs) The licensing agency is required to establish a reasonable length of time to correct a deficiency. In order to set the time, the licensing agency must take into consideration the seriousness of the violation, the number of persons in care involved, and the availability of equipment and personnel necessary to correct the violation. Applicants/licensees are requested to provide a specific plan for each violation on the right side of the form across from each deficiency. The more specific the plan, the less chance exists for any misunderstanding in setting time limits and reviewing corrections. The applicant/licensee who encounters problems beyond their control in completing the corrections within the specified time frame may request and may be granted an extension of the correction due date by the licensing agency.

CORRECTION NOTIFICATION The applicant/licensee is responsible for completing all corrections and promptly notifying the licensing agency of corrections. Applicants/licensees are advised to keep a dated copy of any correspondence sent to the licensing agency concerning corrections, or if corrections are telephoned to the licensing agency, the date, person contacted, and information given.

CIVIL PENALTIES The licensing agency is required by law to issue a Penalty Notice, when applicable, to all facilities holding a license issued by the licensing agency, or subject to licensure, except Certified Family Homes, Resource Families, and Foster Family Homes, or any governmental entity.

PENALTY NOTICE GIVEN The statement concerning civil penalties serves as a penalty notice on this Licensing Report and failure to correct cited licensing deficiencies will result in civil penalties. Applicants/ licensees are required to pay civil penalties when administrative appeals have been exhausted and in accordance with any payment arrangements made with the licensing agency.

APPEAL RIGHTS The applicant/licensee has a right without prejudice to discuss any disagreement in this report with the licensing agency concerning the proper application of licensing requirements. The applicant/ licensee may request a formal review by the licensing agency to amend or dismiss the notice of deficiency and/ or civil penalty. Requests for review shall be made in writing within 15 business days of receipt of a deficiency notification or civil penalty assessment. Licensing deficiencies may be appealed pursuant to the procedures in the LIC 9058 Applicant/Licensee Rights.

AGENCY REVIEW The licensing agency review of an appeal may be conducted based upon information provided in writing by the applicant/licensee. The applicant/licensee may request an office meeting to provide additional information. The applicant/licensee will be notified in writing of the results of the agency review within 60 business days of the date when all necessary information has been provided to the licensing agency.

EMAIL REQUIREMENT Adult Community Care Facilities, Residential Care Facilities for the Chronically Ill, and Residential Care Facilities for the Elderly are required to provide and maintain an active email address of record with the licensing agency.

LIC809 (FAS) - (09/23)

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