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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703268
Report Date: 02/10/2022
Date Signed: 02/10/2022 11:35:49 AM

Document Has Been Signed on 02/10/2022 11:35 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:MOUNTAIN VIEW RESIDENCEFACILITY NUMBER:
561703268
ADMINISTRATOR:CACCAM, VENIS 98FACILITY TYPE:
735
ADDRESS:4359 ISH DR.TELEPHONE:
(805) 583-1948
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 3DATE:
02/10/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:15 AM
MET WITH:Adele Anderson - Administrator TIME COMPLETED:
12:00 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual. This annual had a specific emphasis on infection control practices and procedures. Upon arrival LPA met with Administrator Adele Anderson and explained the reason for the visit.

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. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguisher was fully charged and last serviced March of 2021.

Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable food stored in the fridge and non-perishable food properly stored in a pantry on the exterior of the kitchen. Knives and sharps are stored in a locked cabinet under the sink.



Bedrooms: There were (7) bedrooms total with (1) bedroom designated for staff use. LPA observed staff room to be locked and empty at this time. All bedrooms for clients use were properly furnished and had appropriate bedding and linens.

Bathrooms: There were two bathrooms designated for clients' use. Both bathrooms were clean, properly supplied and had functional fixtures. Hot water temperature was measured between 105.6 - 106.1 degrees Fahrenheit.

Common Areas: These included the living rooms and dining areas. The common areas were properly furnished. Properly labeled medications were observed to be locked in a cabinet in the dining area next to the sliding door. LPA observed multiple board games and activities on the shelves in the living area.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 02/10/2022
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: MOUNTAIN VIEW RESIDENCE
FACILITY NUMBER: 561703268
VISIT DATE: 02/10/2022
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Continued from 809

Surrounding Grounds: Emergency/disaster supplies are properly stored in the garage inaccessible to the clients at this time. The laundry area was located in the garage as well with cleaning supplies inaccessible to clients at this time. LPA observed patio furniture appropriate for outdoor use and plenty of room for outdoor activities. LPA did not observe and obstructions to emergency exits at this time.


INFECTION CONTROL: During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Exit interview conducted. Report issued and sent via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 02/10/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/10/2022
LIC809 (FAS) - (06/04)
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