561703785-7-1-2024-29-AS-BBAI-D6RUJZ-20240701153822

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 561703785
Report Date: 07/01/2024
Date Signed: 07/01/2024 03:39:18 PM

Document Has Been Signed on 07/01/2024 03:39 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 II		FACILITY NUMBER:	561703785
ADMINISTRATOR:	NORMA L. ZANDERS		FACILITY TYPE:	740
ADDRESS:	3190 E. ELMORE STREET		TELEPHONE:	(805) 527-3007
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	6	CENSUS: 5	DATE:	07/01/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	09:45 AM
MET WITH:	Norma Zanders		TIME COMPLETED:	03:45 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the LPA met with staff and explained the reason for the visit. The Administrator, Norma Zanders arrived shortly after. The LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The LPA inspected the kitchen/food service area at 9:30 a.m. The LPA observed two residents having breakfast at the dining table. Knives are stored in a locked cabinet underneath the sink along with cleaning supplies. Kitchen appliances were appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At the time of the visit, the living room furniture was observed to be in good condition. The facility maintained a comfortable temperature of 72 degrees Fahrenheit. Smoke detector(s) and carbon monoxide detector were operational at the time of the visit. LPA observed fire extinguisher to be fully charged and scheduled to be service by the end of the month. The LPA observed four (4) resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. The resident restrooms 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. The hot water temperature was measured in each restroom between 105 - 120 degrees Fahrenheit. The staff room was observed to be inaccessible to residents in care and empty during the time of the visit. Continued on 809

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024

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 II	FACILITY NUMBER: 561703785
	VISIT DATE: 07/01/2024

NARRATIVE

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Continued from 809
All exits have functioning auditory devices and were operational at the time of the visit. The LPA observed required postings throughout the common space. The backyard has a covered outdoor area equipped with furniture including a table and chairs for resident use. The LPA observed one (1) self-latching gate with clear passageways clear of obstruction. There were no bodies of water noted at the time of the visit.

Records review began at 11:00 am, five (5) Personnel records were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR training, and the appropriate training. five (5) resident records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All files were observed to be in order at this time.

Medications review began at 1:00 p.m. The medications are centrally stored and locked in a cabinet adjacent to the kitchen. Medications are labeled and checked for expiration dates. No errors found during medication audit.

INFECTION CONTROL: Upon entry, the facility has a central entry point for symptom screening, temperature checks, and sanitation station. At this time, the staff will continue to keep up signs that promotes good hand hygiene and symptoms of a communicable disease. The facility has 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 an infectious disease. The facility’s policies and procedures as it pertains to infection control are adequate.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report, LIC9020 Client Roster, a copy of the emergency disaster plan, and a copy of the facility’s liability insurance. Staff and residents were interviewed during the visit.

Exit interview conducted. A copy of the report and appeal rights was provided to the Administrator.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Brian Balisi	TELEPHONE: (818) 421-9171
LICENSING EVALUATOR SIGNATURE:	DATE: 07/01/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/01/2024

LIC809 (FAS) - (06/04)

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