561703268-2-4-2025-29-AS-MARO-DDKTTE-20250204140037

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561703268
Report Date: 02/04/2025
Date Signed: 02/04/2025 02:01:41 PM

Document Has Been Signed on 02/04/2025 02:01 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 RESIDENCE		FACILITY NUMBER:	561703268
ADMINISTRATOR/ DIRECTOR:	KIRSTIE A THOMPSON		FACILITY TYPE:	735
ADDRESS:	4359 ISH DR.		TELEPHONE:	(805) 583-1948
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 4		CENSUS: 4	DATE:	02/04/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:30 AM
MET WITH:	Kirstie Thompson / Venis Caccam		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, there was one (1) staff. Clients were in day program during the inspection. The staff contacted the Licensee via telephone and explained the reason for the visit. The Licensee, Venis Caccam arrived at approximately 10:00am. The Administrator, Kirstie Thompson arrived during the inspection. Entrance interview conducted.

Starting at 10:08 a.m., the LPA along with the Licensee 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 following was observed:

KITCHEN: The LPA inspected the kitchen/food service area at 10:25am. Knives and sharps were observed locked and inaccessible under the kitchen sink. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Refrigerator and food pantry were checked for proper labels and expiration dates; expiration dates were clearly marked.

COMMON AREAS: At the time of the visit, furniture in the common areas was observed to be in good condition. The facility maintained a comfortable temperature. Required postings were observed throughout the common space.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

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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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: 02/04/2025

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Report Continued from LIC 809...

Activities were observed in the living room and dining room. There is a working telephone on premises. The LPA observed a closet in the hallway with additional clean linens and towels. Auditory alarms were observed at the time of the visit.

RESTROOMS: There are two (2) restrooms for client use. Bathrooms were clean and sanitary and in operating condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Starting at 10:13am, the hot water temperature was measured in both bathroom and they measured between 110.4 and 114.6 degrees Fahrenheit.

BEDROOMS: There are four (4) bedrooms for client use. All bedrooms are designated as private rooms. All client rooms were observed to be furnished appropriately with linens, appropriate furnishings, and sufficient lighting. The LPA observed a staff bedroom on premises.

GARAGE: The garage was locked and inaccessible to clients at the time of the visit. The LPA observed an adequate amount of emergency food and water. Washer and dryer were observed inside the garage. Additional cleaning supplies are kept locked and inaccessible to clients in care.

BACKYARD: The backyard has a covered patio area with patio furniture for client use. All passageways were observed to be clear of any obstructions. There are two (2) side gates with latching mechanisms. No bodies of water noted at the time of the visit.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

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: 02/04/2025

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Report Continued from LIC 809C...

RECORDS: The LPA reviewed Client Records at 11:03am and Personnel Records at 11:50am.

Four (4) client files were reviewed 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/IPP. All files were in order.

Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate yearly training. All records were in order.

Administrator’s Certificate is valid until 06/20/2025.

During today's inspection, the LPA conducted one (1) staff interview. No concerns noted.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control plan. The facility’s policies and procedures as it pertains to infection control are adequate. LPA also reviewed the facility's emergency disaster plan, which was observed to be complete and recently reviewed/updated. Emergency disaster drills conducted quarterly as per regulation; last one conducted on 01/30/2025. The LPA observed the fire extinguisher to be fully charged with a date of 04/29/2024.

MEDICATIONS: Medications review began at approximately 10:40am. The medications are locked in a cabinet adjacent to the dining room. All medications including PRNs were labeled, stored, and locked inaccessible to clients in care. Medications appeared to be given as prescribed at the time of the visit.

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

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/04/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/04/2025

LIC809 (FAS) - (06/04)

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