561703599-1-7-2025-29-AS-MARO-DCPTQC-20250107135542

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561703599
Report Date: 01/07/2025
Date Signed: 01/07/2025 01:55:58 PM

Document Has Been Signed on 01/07/2025 01:55 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 ELDERLY		FACILITY NUMBER:	561703599
ADMINISTRATOR/ DIRECTOR:	NORBERTO LAIGO		FACILITY TYPE:	740
ADDRESS:	3967 EAST DOWNEY COURT		TELEPHONE:	(805) 527-3278
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 6	TOTAL ENROLLED CHILDREN: 0	CENSUS: 4	DATE:	01/07/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:15 AM
MET WITH:	Norma Zanders		TIME VISIT/ INSPECTION COMPLETED:	02:00 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there were two (2) staff and four (4) residents. The staff contacted the Administrator via telephone and explained the reason for the visit. The Administrator, Norma Zanders arrived during the inspection. Entrance interview conducted.

Starting at 9:35am, the LPA along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of non-perishable and perishable food; properly stored. Refrigerator and dry food pantry were checked for proper labels and expiration dates. Knives and sharps were observed locked an inaccessible under the kitchen sink. At 09:42am, the kitchen sink was measured for hot water temperature, and it measured 112. 4 degrees Fahrenheit.

BEDROOMS: There are three (3) bedrooms for resident use and one (1) bedroom designated for staff only. Two (2) resident bedrooms are designated as double occupancy; and one (1) resident bedroom is designated as single occupancy. The LPA observed all resident bedrooms to be properly furnished and with sufficient lighting. Additional clean linens and towels for resident use were observed in a closet.

Report Continued on LIC 809C...

Desaree Perera	TELEPHONE: (818) 596-4347
Martha Arroyo	TELEPHONE: (818) 421-6459
	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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: LAIGO-ZANDERS HOME FOR THE ELDERLY	FACILITY NUMBER: 561703599
	VISIT DATE: 01/07/2025

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Report Continued from LIC 809...

BATHROOMS: There are two (2) bathrooms for resident use. Bathrooms were observed to be equipped with nonskid surfaces and grab bars. The LPA observed bathrooms to be properly supplied and had functional fixtures. Hand washing signs were observed posted in bathrooms. Starting at 09:48am., the water temperature was measured in both bathrooms, and they measured between 112.8 and 116 degrees Fahrenheit.

COMMON AREAS: The LPA observed the living room and dining room area to be furnished appropriately and all furniture was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. The LPA observed required postings throughout the common space. Activities for residents were observed in the living room. There is a working telephone on premises. The LPA observed working auditory alarms at the time of the visit. Fireplace was observed adequately covered. Facility has an adequate amount of emergency food and water. At 09:51am, smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. No obstructions or hazards were observed inside or out.

GARAGE / OUTDOOR: The garage was observed inaccessible to residents in care at the time of the visit. Washer and dryer were observed inside the garage. Detergents and cleaning solutions were observed in a locked cabinet at the time of the visit. There is a shaded area in the backyard with appropriate furniture for resident use. The exterior passageways were clean and clear of any obstructions. The LPA observed one (1) self-latching gate for emergency use. No bodies of water noted at the time of the visit.

RECORD REVIEW: The LPA reviewed four (4) Resident Records and four (4) Personnel Records including the current Administrator’s file starting at 10:05am.

Report Continued on LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

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: LAIGO-ZANDERS HOME FOR THE ELDERLY	FACILITY NUMBER: 561703599
	VISIT DATE: 01/07/2025

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Report Continued from LIC 809C...

Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, consent for treatment form, and current needs and services plan. All files were complete.

Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR certifications, and yearly training. All records were in order.

Administrator’s Certificate is active until 03/26/2026.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. Fire extinguisher was observed to be fully charged on 10/31/2024. Emergency disaster drills are conducted quarterly, with the last one conducted on 12/18/2024.

MEDICATION REVIEW: The LPA conducted a medication review at approximately 12:00pm. Medications are locked in a file cabinet adjacent to the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. The LPA observed PRN authorization letters for all residents on file. Medications appeared to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. Report was reviewed and a copy was provided.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:	DATE: 01/07/2025

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/07/2025

LIC809 (FAS) - (06/04)

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