565800010-9-3-2024-29-AS-MARO-D8RSEG-20240903134844

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800010
Report Date: 09/03/2024
Date Signed: 09/03/2024 01:48:54 PM

Document Has Been Signed on 09/03/2024 01:48 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/ DIRECTOR:	KIRSTIE A THOMPSON		FACILITY TYPE:	735
ADDRESS:	4347 ISH DRIVE		TELEPHONE:	(805) 583-1783
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 4		CENSUS: 3	DATE:	09/03/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:00 AM
MET WITH:	Kirtstie Thompson		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 was one (1) staff. Three (3) residents were at day program at the time of the visit. LPA was greeted by facility staff who contacted the facility administrator via telephone. Administrator Kirstie Thompson arrived shortly after and the reason for the visit was explained. Entrance interview conducted.

During today’s visit, the LPA along with the Administrator 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 seven (7) days non-perishable and two (2) days perishable food; properly stored. Refrigerator and dry food pantry were checked for proper labels and expiration dates and food labels had expiration dates clearly marked. Knives and sharps were observed under the sink locked and inaccessible. The kitchen faucet was measured for water temperature, and it measured 107.4 degrees Fahrenheit.

BEDROOMS: There are four (4) total bedrooms in the facility for clients. LPA observed all client bedrooms to be properly furnished with a bed, nightstand, and sufficient lighting. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. There is a locked closet with client’s personal hygiene items and cleaning supplies.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

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: MOUNTAIN VIEW RESIDENCE II	FACILITY NUMBER: 565800010
	VISIT DATE: 09/03/2024

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Report Continued from LIC 809...

BATHROOMS: There are two (2) bathrooms for client use. Bathrooms were observed to be equipped with nonskid surfaces and grab bars. LPA observed bathrooms to be clean, properly supplied and had functional fixtures. Starting at 9:34 a.m., the water temperature was measured in both bathrooms, and they measured between 105.6 and 108.1 degrees Fahrenheit.

COMMON AREAS: This includes the living room and dining room areas. LPA observed common area to be clean and properly furnished at the time of the visit. Appropriate signage regarding infection control posted throughout the facility. LPA observed sanitizer readily available in areas with high touch surfaces. Common room furniture was observed to be in good condition. The facility maintained a comfortable temperature. Fire extinguisher was observed to be fully charged on 04/29/2024. Hardwired combination smoke and carbon monoxide detectors were tested at 9:52 a.m. and all were functional at the time of the visit. No fire clearance concerns were observed. There is a working telephone on premises. There is a laundry room by the staff office. Detergents and cleaning supplies were observed in a locked closet inside the laundry room. Staff assist clients with all laundry needs.

OUTDOOR / BACKYARD: There is a shaded area in the backyard with a table and chairs for client use. The exterior passageways were clean and clear of any obstructions. There were no bodies of water noted at the time of the visit. LPA observed one (1) self-latching gate for emergency use.

RECORD REVIEW: LPA reviewed three (3) Client Records and two (2) Personnel Records including the current Administrator’s file starting at 10:00 a.m.

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 complete.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

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: 09/03/2024

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Report Continued from LIC 809C...

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.

The Administrator certificate is valid until 06/10/2025.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2-i home.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, 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. Emergency disaster drills are conducted quarterly, with the last one conducted on 08/29/2024.

MEDICATION REVIEW: LPA conducted a medication review at approximately 12:00 p.m. Medications are locked in a cabinet adjacent to the living room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit.

During today’s visit, LPA conducted an interview with one (1) staff member and obtained copies of Personnel Report (LIC 500), Client Roster (LIC 9020), Emergency Disaster Plan (LIC 610D), Limited Liability Insurance, and Surety Bond.

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

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/03/2024

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/03/2024

LIC809 (FAS) - (06/04)

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