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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 425802115
Report Date: 02/18/2025
Date Signed: 02/18/2025 04:37:39 PM

Document Has Been Signed on 02/18/2025 04:37 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 CAREFACILITY NUMBER:
425802115
ADMINISTRATOR/
DIRECTOR:		MARIA ZEPEDAFACILITY TYPE:
735
ADDRESS:505 SAINT ANDREW WAYTELEPHONE:
(805) 733-0112
CITY:LOMPOCSTATE: CAZIP CODE:
93436
CAPACITY: 4CENSUS: 4DATE:
02/18/2025
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Vincent Hernandez/StaffTIME VISIT/
INSPECTION COMPLETED:
05:00 PM
NARRATIVE
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Licensing Program Analyst (LPA) Haner-Tomasko and Licensing Program Manager (LPM) Burley conducted an unannounced case management visit to issue a deficiency discovered while investigating a complaint.

LPA observed staff roster and files, and was told Staff 1 (S1) works in the facility. LPA observed S1 has fingerprint clearance, but was not associated to the facility.

Exit interview, deficiency cited on 809-D, report given, appeal rights given.
SUPERVISORS NAME: Kelly Burley
LICENSING EVALUATOR NAME: Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE: DATE: 02/18/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/18/2025
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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Document Has Been Signed on 02/18/2025 04:37 PM - It Cannot Be Edited


Created By: Garrett Haner-Tomasko On 02/18/2025 at 04:09 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMMONS RESIDENTIAL CARE
FACILITY NUMBER: 425802115

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 02/18/2025
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
02/19/2025
Section Cited
CCR
87355(e)(1)

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All individuals subject to a criminal record review pursuant to Health and Safety Code Section 1569.17(b) shall prior to working, residing or volunteering in a licensed facility: Request a transfer of a criminal record clearance as specified in Section 87355(c). This requirement was not met as
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Licensee associated S1 in Guardian during the visit.
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evidenced by: Based on record review and interview, the licensee did not comply with the section cited above when S1 was not associated to the facility, which posed an immediate health and safety risk to clients inc are.
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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:Kelly Burley
LICENSING EVALUATOR NAME:Garrett Haner-Tomasko
LICENSING EVALUATOR SIGNATURE:
DATE: 02/18/2025
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/18/2025


LIC809 (FAS) - (06/04)
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