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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800106
Report Date: 01/25/2022
Date Signed: 01/25/2022 02:52:20 PM

Document Has Been Signed on 01/25/2022 02:52 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:QUALITY CARE HOMEFACILITY NUMBER:
565800106
ADMINISTRATOR:MARIA CASTILLO 98FACILITY TYPE:
735
ADDRESS:4859 EAST MUIRWOOD COURTTELEPHONE:
(805) 579-9605
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 3CENSUS: 1DATE:
01/25/2022
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:00 PM
MET WITH:Maria Castillo - Administrator TIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Brian Balisi arrived at the facility unannounced to conduct a required annual. This annual had a specific emphasis on infection control practices and procedures. Upon arrival LPA was met by Administrator Maria Castillo.
Facility is a Level II home, vendored by Tri-Counties Regional Center serving a developmentally disabled client. There is currently one client residing at the facility, who does not require 1:1 staffing.
LPA toured the physical plant areas inside and outside to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke alarms were tested and all functioned properly. The fire extinguishers were fully charged and last serviced on November 2021. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA found a sufficient amount of perishable and non-perishable food at the facility; properly stored. Knives and sharps are stored in a locked drawer to the right of the fridge. Properly labeled medications were locked in a lock box in in a cabinet to the right of the microwave.

Bedrooms: There are five bedrooms total. One bedroom designated for clients' use. The bedroom was observed to be properly furnished and had appropriate bedding and linens. At 1:15pm, LPA observed client watching television in the room. Three bedrooms are occupied by the licensee and her family. One bedroom is being used as an office. LPA observed a sufficient supply of linens, and towels in the hallways closets.



Bathrooms: Bathroom was clean, properly supplied and had functional fixtures. Hot water temperature was measured at 113 degrees Fahrenheit.

Common Areas: These included the living rooms and dining areas. The common areas were properly furnished. Detergents and chemicals are kept in the garage, locked and inaccessible to the client. Emergency food supplies and water are kept in a pantry in the garage.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/25/2022
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
Page: 1 of 2
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: QUALITY CARE HOME
FACILITY NUMBER: 565800106
VISIT DATE: 01/25/2022
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Continued from 809

Surrounding Grounds:


The backyard is divided into two separate areas by a gate. One side contains a storage shed, LPA observed shed to be full of various storage items at this time. The other side contains a BBQ area, swings, playhouse, tables with chairs. There are no bodies of water or firearms/ ammunition on the property at this time.

INFECTION CONTROL: During today’s visit, LPA spoke with the Administrator regarding the facility’s infection control practices. Upon entry, the facility has a central entry point for symptom screening, temperature checks, and a sanitation station. LPA observed an adequate supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. If needed, the facility has the capacity to designate a single isolation room if the facility has a confirmed case of COVID-19. The facility has not had a confirmed case of COVID-19 at this time; however, the facility’s policies and procedures as it pertains to infection control are adequate.

Exit interview conducted. Report issued and sent via email.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE:

DATE: 01/25/2022
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/25/2022
LIC809 (FAS) - (06/04)
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