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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800045
Report Date: 10/15/2024
Date Signed: 10/15/2024 10:16:35 AM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 10/15/2024 10:16 AM - 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:
10/15/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Giovanni FulgentesTIME COMPLETED:
10:30 AM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit. Upon arrival, the facility appeared vacant. LPA contacted the Administrator, Maria Mendez via telephone and at this time, the reason for the visit was explained. Facility Manager, Giovanni Fulgentes arrived shortly after. Entrance interview.

The Facility Manager stated the facility currently has no residents as the facility is undergoing a remodel. Facility Manager stated that they are not admitting any residents until all remodeling is complete and upgrades have been made.

The LPA and Facility Manager toured the physical plant areas inside and outside; there were no residents or staff observed at the facility. Bathrooms have been remodeled and new flooring throughout the facility is installed. The ceiling has been repaired to a leak from the fire suppression system. At 10:07am, smoke and carbon monoxide detectors were tested and operational at the time of the visit. LPA did not observe any structural change/addition only cosmetic upgrades/repairs.

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



Exit interview conducted. Report was reviewed and issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 10/15/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/15/2024
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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