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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 561703599
Report Date: 02/11/2022
Date Signed: 11/14/2022 02:15:09 PM


Document Has Been Signed on 11/14/2022 02:15 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:LAIGO-ZANDERS HOME FOR THE ELDERLYFACILITY NUMBER:
561703599
ADMINISTRATOR:NORBERTO LAIGOFACILITY TYPE:
740
ADDRESS:3967 EAST DOWNEY COURTTELEPHONE:
(805) 527-3278
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY:6CENSUS: 5DATE:
02/11/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:15 AM
MET WITH:Norberto LaigoTIME COMPLETED:
10:45 AM
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Required - 1 Year inspection at the facility today. At 9:15 AM the LPA met with Administrator and explained the reason for the inspection. Today's annual has an emphasis on infection control practices and procedures.

The LPA, along with Administrator, toured the physical plant areas inside and outside beginning at 9:30AM to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations.

COMMON SPACES: The common areas were observed. The fire extinguishers were observed to be last serviced on 11/021. The smoke alarms and carbon monoxide detectors were tested in the common area and observed operational. The facility has a sufficient supply of perishable and non-perishable food. There is outdoor seating in the backyard for resident visitation use. Cleaning supplies are secured in the locked garage. BEDROOMS: The LPA observed the resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting.

RESTROOMS: There are two resident bathrooms. Bathrooms had hand soap, paper towels, and signs regarding proper hand washing.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. There is 1 entry into the facility. Upon entry, the facility has a central entry point for symptom screening. The LPA observed an adequate supply of Personal Protective Equipment (PPE). 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 following recommendations were made: Posting Provider Information Notices (PINs) and educating staff and clients on changing policies and procedures from the Department.


- Arrange N95 fit testing for staff. No deficiencies cited.
Exit interview conducted. Signatures obtained. A copy of the report was emailed.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4337
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 02/11/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 02/11/2022
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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