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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800045
Report Date: 10/23/2023
Date Signed: 10/23/2023 06:14:22 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/23/2023 06:14 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:SIMI VALLEY RESIDENTIAL CARE IIFACILITY NUMBER:
565800045
ADMINISTRATOR:WALTER & MARIA MENDEZFACILITY TYPE:
740
ADDRESS:713 ERRINGER RD.TELEPHONE:
(805) 522-9129
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 0DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
05:04 PM
MET WITH:Maria MendezTIME COMPLETED:
05:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at this facility with Licensee Maria Mendez and explained the reason for the visit. The licensee stated the facility currently has no residents as the facility is undergoing a remodel. Licensee stated that they are not admitting any residents until all remodeling is complete and upgrades have been made.

The LPA and Licensee toured the physical plant areas inside and outside; there were no residents or staff observed at the facility. According to the licensee the layout of the facility will not be changing. Bathrooms are being remodeled, new doors are being installed; new flooring throughout the facility is installed. The ceilings are repaired due to a leak from the fire suppression system. Smoke and carbon monoxide detectors are disabled due to the remodel. LPA did not observe any structural change/addition only cosmetic upgrades/repairs. Licensee confirmed that there will be no structural changes/additions. Licensee did stated that she may convert all rooms for resident use (no staff room).

The licensee stated that she will retain their license but will not admit residents until the property has been fully remodeled and all safety checks have been completed. Licensee agreed to inform the licensing department when all work is completed and facility will resume with admissions.



Exit interview conducted. A copy of report emailed to licensee.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
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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