561701197-12-22-2022-29-AS-MARO-CMCR8Z-20221222114846

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561701197
Report Date: 12/22/2022
Date Signed: 12/22/2022 11:49:28 AM

Document Has Been Signed on 12/22/2022 11:49 AM - 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:	IBARRA ADULT RESIDENTIAL CARE HOME		FACILITY NUMBER:	561701197
ADMINISTRATOR:	MARIA S. CASTILLO		FACILITY TYPE:	735
ADDRESS:	5228 KATHERINE ST		TELEPHONE:	(805) 842-1061
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 4		CENSUS:	DATE:	12/22/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Maria Ibarra		TIME COMPLETED:	11:50 AM

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

Licensing Program Analyst (LPA), Martha Arroyo arrived unannounced to conduct a Required 1-Year Annual Inspection with focus on Infection Control at 9:45 a.m. The last Annual visit conducted at this facility was on 01/21/2022. Upon arrival, the LPA was scanned and greeted at the door by Administrator, Maria Ibarra and the reason for the visit was explained. Entrance interview.

At 9:56 a.m., the LPA began the physical plant tour of the common areas, kitchen area, client bedrooms, bathrooms, staff room, and outdoor area to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

KITCHEN: The kitchen appeared clean and the appliances and fixtures functional. The facility has a sufficient supply of seven (7) days perishable and two (2) days non-perishable food. The LPA observed one designated cabinet next to the oven where knives and sharps kept locked and inaccessible to clients.

BEDROOMS: The LPA observed all three (3) client rooms which were properly furnished, and had appropriate bedding, linens, and sufficient lighting. There is one (1) staff room that is kept locked.

RESTROOMS: Client restrooms are clean and sanitary and in operating condition with functional fixtures. Restrooms are sufficiently stocked with hand liquid soap and paper towels. The appropriate hand-washing signs were observed throughout. Bathrooms were measured for hot water; the first bathroom measured at 105.6 degrees Fahrenheit at 10:05 a.m. and the second bathroom measured at 108.1 degrees Fahrenheit at 10:12 a.m.

…Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

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 2

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: IBARRA ADULT RESIDENTIAL CARE HOME	FACILITY NUMBER: 561701197
	VISIT DATE: 12/22/2022

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

…Report Continued from LIC 809...

GARAGE AND GROUNDS: The garage is locked and attached to the house. Cleaning supplies and chemicals were observed in a locked cabinet inaccessible to clients. The LPA observed one (1) additional refrigerator and freezer fully stocked at the time of visit. There is a pantry with a sufficient supply of emergency food and water. There is a covered patio area with patio furniture for client use. There is a pool in the backyard that is kept locked and secured from clients.

COMMON SPACES: The living and dining areas are clean and properly furnished with seating and a table for client use. Medication was observed locked in a cabinet next to the dining room. The fire extinguisher was observed and last serviced on 08/06/2022. There are four (4) clients in this home; however, all clients were at the day program at the time of visit.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed appropriate signage which promoted good hand hygiene, physical distancing, symptoms of COVID-19, and CDSS PINS. The facility has a central entry point for symptom screening, temperature checks, and sanitation station. The LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. All staff and residents are fully vaccinated. No identified staffing concerns.

Exit interview conducted. No citations issued. A copy of the report was provided via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 12/22/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/22/2022

LIC809 (FAS) - (06/04)

Page: 2 of 2