565800010-9-23-2023-29-AS-MARO-CVXQP2-20230923122002

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800010
Report Date: 09/23/2023
Date Signed: 09/23/2023 12:20:07 PM

Document Has Been Signed on 09/23/2023 12:20 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 II		FACILITY NUMBER:	565800010
ADMINISTRATOR:	KIRSTIE A THOMPSON		FACILITY TYPE:	735
ADDRESS:	4347 ISH DRIVE		TELEPHONE:	(805) 583-1783
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 6		CENSUS: 5	DATE:	09/23/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Venis Caccam / Kirstie Thompson		TIME COMPLETED:	12:30 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 8:00 a.m. The last annual conducted at this facility was on 08/29/2022. Upon arrival, the LPA met with Staff, Elisea Marcelo; the Licensee, Venis Caccam arrived at 8:15 a.m. and at this time, the reason for the visit was explained. The Administrator Kirstie Thompson arrived during the inspection. Entrance interview conducted.

At 8:20 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.

KITCHEN: The LPA inspected in the kitchen/food service area at 8:26 a.m. At 8:27 a.m., the hot water temperature was measured in the kitchen at 105.9 degrees Fahrenheit. Kitchen appliances appeared clean and were in operable condition at the time of the visit. The facility has a sufficient supply of perishable and non-perishable food. Additional groceries were delivered at the time of the visit. Food labels were inspected and checked for dates and expiration dates and food labels had expiration date clearly marked. The LPA observed knives and sharps locked under the kitchen sink. Cleaning supplies and disinfectants are kept under the kitchen sink locked and inaccessible to clients in care.

COMMON AREAS: At the time of the visit, living room and dining room furniture was observed to be in good condition. The facility maintained a comfortable temperature. At 8:31 a.m., the smoke detector(s) and carbon monoxide detector were tested and operational at the time of the visit. The fire extinguishers were fully charged and were last serviced 4/27/2023. The LPA observed required postings throughout the common space. There is a functioning telephone on the premises for client use.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

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 II	FACILITY NUMBER: 565800010
	VISIT DATE: 09/23/2023

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(Report Continued from LIC 809...)

There is a separate laundry room, which is kept locked. Clients have scheduled laundry days and are responsible for their own laundry needs; however, the staff is present and assists at all times.

GARAGE/BACKYARD: The LPA observed a sufficient supply of emergency food and water. Cleaning supplies, detergents, and toxins were observed locked and inaccessible to clients. The LPA observed a sufficient supply of Personal Protection Equipment (PPE). The backyard has a covered outdoor area equipped with tables and chairs for client use. The facility has two (2) side gates that self-close. Passageways were observed clear and free of obstructions in case of an emergency. No bodies of water noted at the time of the visit.

BEDROOMS: There are six (6) private client bedrooms. The LPA observed the client bedrooms to be furnished appropriately with clean linens, appropriate furnishings, and sufficient lighting. There is a staff room on premises. The LPA observed a linen closet in the hallway with extra towels and linens.

RESTROOMS: There are two (2) restrooms for client use. The 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; towels and washcloths are not shared. The hot water temperature was measured in both bathrooms; the first bathroom measured at 106.3 degrees Fahrenheit at 8:23 a.m.; and the second bathroom was measured at 110.8 degrees Fahrenheit at 8:30 a.m.

RECORDS: The LPA reviewed five (5) client records at 8:46 a.m. and three (3) staff records at 9:57 a.m. Client records were reviewed for, but not limited to: appraisals, medical records, admissions agreement, consent forms. All records were in order.

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

The LPA also audited the current Administrator’s file, and it was in order.

(Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

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 II	FACILITY NUMBER: 565800010
	VISIT DATE: 09/23/2023

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(Report Continued from LIC 809C...)

MEDICATIONS: Medications review began at 10:25 a.m.; medications are centrally stored and locked in a cabinet adjacent to the living room. All medications including PRNs were labeled, stored, and locked inaccessible to clients. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No errors observed during the medication review.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2 – Home. The last disaster drill was conducted on 08/29/2023.

At the time of the visit, the LPA obtained the following documents: LIC500 Personnel Report, LIC9020 Client Roster, and a copy of the liability insurance.

The LPA conducted interviews with one resident at 8:10 a.m.

No deficiencies were noted at this time. Exit interview conducted. Report was reviewed and a copy was issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/23/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/23/2023

LIC809 (FAS) - (06/04)

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