561701197-1-25-2024-29-AS-MARO-CZTSLK-20240125125829

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561701197
Report Date: 01/25/2024
Date Signed: 01/25/2024 12:59:01 PM

Document Has Been Signed on 01/25/2024 12:59 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, 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: 4	DATE:	01/25/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Maria Ibarra		TIME COMPLETED:	01:15 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 8:00 a.m. The last annual conducted at this facility was on 12/22/2022. When the LPA arrived, there were two (2) staff and four (4) clients present. The LPA was greeted at the door by Administrator, Maria Ibarra, and at this time the reason for the visit was explained. Entrance interview conducted.

At 8:10 a.m., the LPA along with the Administrator, 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.

Kitchen: The kitchen area was observed at 8:21 a.m. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates and food labels had expiration date clearly marked. The knives and sharps are stored in a locked cabinet next to the oven inaccessible to clients in care.

Common areas: Living and dining room furniture were observed to be in good condition. At 8:29 a.m., smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The LPA observed required postings throughout the common space. The fire extinguisher was last charged and serviced on 08/04/2023. The LPA observed an adequate supply of emergency food and water.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

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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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: 01/25/2024

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(Report Continued from LIC 809...)

Outdoor: The laundry area was in the back room off the dining area, detergents and cleaning supplies are kept in a locked cabinet. Staff assist clients with all laundry needs. The backyard has a covered outdoor area equipped with furniture for client use. The pool is kept secured from clients. All indoor and outdoor passageways were free from obstructions in case of an emergency.

Restrooms: There are two restrooms for client use which were observed clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms; first bathroom measured at 108.6 degrees Fahrenheit at 8:19 a.m.; and the second bathroom measured at 107.7 degrees Fahrenheit at 8:27 a.m.

Bedrooms: There are three (3) client bedrooms; one (1) bedroom is double occupancy, and two (2) bedrooms are single occupancy. All bedrooms were furnished with appropriate linens and required furniture. Adequate lighting in all bedrooms was observed.

Records: The LPA reviewed facility files at 8:40 a.m. The LPA reviewed four (4) client files for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan. All files were complete.

The LPA reviewed three (3) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, current first aid/cpr certification, and yearly training. All files were complete.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2-i home. The last disaster drill was conducted on 12/04/2023.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC809 (FAS) - (06/04)

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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: 01/25/2024

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(Report Continued from LIC 809C...)

Medications: Medications review began at approximately 10:25 a.m.; medications are centrally stored and locked in a cabinet adjacent to the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to clients. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. Medications are properly documented on the centrally stored medications and destruction record. No errors observed during the medication review.

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

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/25/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2024

LIC809 (FAS) - (06/04)

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