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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800073
Report Date: 07/19/2024
Date Signed: 07/19/2024 03:27:42 PM


Document Has Been Signed on 07/19/2024 03:27 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:
07/19/2024
TYPE OF VISIT:Case Management - Legal/Non-complianceUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Annabelle RamosTIME COMPLETED:
03:30 PM
NARRATIVE
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Licensing Program Analyst (LPA) Martha Arroyo conducted an unannounced cased management – legal/non-compliance visit. The purpose of today’s visit was to ensure the facility is maintaining substantial compliance as outlined in the Stipulation and Waiver, and Order. The order is effective May 3, 2023 – May 3, 2025. A copy of the Stipulation and Waiver; And Order is posted in the living room by the entry way of the facility. The Administrator, Annabelle Ramos arrived at 2:05 p.m. and at this time the reason for the visit was explained. The LPA focused today’s visit on resident records and personnel records.

During today’s visit, the LPA along with the Administrator conducted a plant tour to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations.

The LPA conducted a records review at approximately 2:20pm: Five (5) resident 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. The LPA also reviewed two (2) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and current first aid certification. All files were complete.

No deficiencies issued. Exit interview conducted. Report was reviewed and copy was issued.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha ArroyoTELEPHONE: (818) 421-6459
LICENSING EVALUATOR SIGNATURE:
DATE: 07/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/19/2024
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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