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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703268
Report Date: 01/06/2025
Date Signed: 01/06/2025 04:26:08 PM

Document Has Been Signed on 01/06/2025 04:26 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:MOUNTAIN VIEW RESIDENCEFACILITY NUMBER:
561703268
ADMINISTRATOR/
DIRECTOR:
KIRSTIE A THOMPSONFACILITY TYPE:
735
ADDRESS:4359 ISH DR.TELEPHONE:
(805) 583-1948
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 4CENSUS: 4DATE:
01/06/2025
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
03:00 PM
MET WITH:Kirstie ThompsonTIME VISIT/
INSPECTION COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced Case Management - Incident visit to follow up on an Incident Report (LIC 624) received by the department on 01/06/2025. Upon arrival, the LPA met with staff who contacted the Administrator via telephone. The Administrator, Kirstie Thompson arrived shortly after and the reason for the visit was explained. Entrance interview conducted.

The written report which contained information regarding an incident from 01/03/2025 at approximately 2:37pm, involving Staff #1 (S1) being stabbed multiple times by an unknown subject. Two residents present during the incident were unharmed. S1 was transferred to the hospital where they are currently located. Police Department was notified.

During today’s visit, LPA Arroyo conducted a physical plant tour, interviewed the Administrator, one staff, three residents, and conducted a file review and obtained copies of pertinent documents. The LPA has determined further investigation is needed and will return at a later date to complete the investigation if warranted.

No immediate or potential health and safety concerns noted at this time.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 01/06/2025
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/06/2025
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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