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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800073
Report Date: 08/23/2023
Date Signed: 08/25/2023 04:31:53 PM


Document Has Been Signed on 08/25/2023 04:31 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:GREEN VALLEY HOME CAREFACILITY NUMBER:
565800073
ADMINISTRATOR:ZANDERS, NORMAFACILITY TYPE:
740
ADDRESS:2651 BANCOCK STREETTELEPHONE:
(805) 579-0040
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:45 AM
MET WITH:Norma ZandersTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a required annual visit to this facility. LPA was greeted by administrator. Reason for visit was stated. Upon arrival, LPA and administrator conducted a physical plant tour for compliance with safety, maintenance and operational requirements. The facility has six (6) bedrooms and two (2) bathrooms. Smoke detectors and Carbon Monoxide detector were observed/tested and function properly. Fire extinguisher located in kitchen area observed operable with last service date of 07/22/2023. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non- perishable food at the facility; properly stored. Sharp objects are stored in locked kitchen cabinet/drawer. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident; appropriate and adequate bedding and linens observed for each resident. Bathrooms: Both bathrooms observed clean, functional fixtures and properly supplied. LPA observed grab bars and non-skid mats in both bathrooms. Sufficient amounts of supplies for personal hygiene observed. Common Areas: These included the living room, family room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. Surrounding Grounds (Outdoors): Surroundings observed clean and hazard free. There is a pool which is empty and gated; inaccessible for residents safety.
Resident records reviewed at approximately 11am. All residents have a current annual physician report, current assessment and admission agreement on file. Staff records reviewed at approximately 11:30am. Staff have current first aid and record of required training completed. Emergency disaster drill observed posted reviewed 8/24/2023; All other required postings observed posted.
Medications reviewed 12pm: Records included physician orders for medications and centrally stored medication logs. Medications are stored inaccessible in a locked cabinet in the living room area. first aid kit observed to be complete with all required items.
Licensee is in compliance with the California Code of Regulations (CCR), Title 22, Division 6, Chapter 8.
Exit interview conducted, copy of report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 08/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/25/2023
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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