565800106-1-13-2025-29-AS-MARO-DCVV3B-20250113150426

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800106
Report Date: 01/13/2025
Date Signed: 01/13/2025 03:04:34 PM

Document Has Been Signed on 01/13/2025 03:04 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 HOME		FACILITY NUMBER:	565800106
ADMINISTRATOR/ DIRECTOR:	MARIA CASTILLO 98		FACILITY TYPE:	735
ADDRESS:	4859 EAST MUIRWOOD COURT		TELEPHONE:	(805) 579-9605
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 3		CENSUS: 1	DATE:	01/13/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	12:30 PM
MET WITH:	Robert Castillo		TIME VISIT/ INSPECTION COMPLETED:	03:15 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. Upon arrival, there was one (1) staff member present. One (1) resident is currently at day program. The LPA was greeted by facility staff who contacted the Administrator via telephone. At this time, the LPA explained the reason for the visit. The Administrator stated they were unable to come to the facility but gave permission for staff to sign report. Entrance interview conducted.

Starting at 1:50pm, the LPA along with staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen to be clean. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of non-perishable and perishable food; properly stored. Refrigerator and dry food pantry were checked for proper labels and expiration dates. The knives and sharps are stored in a locked cabinet inside the food pantry inaccessible to clients in care.

BEDROOMS: There is one (1) bedroom for resident use. The LPA observed resident bedroom to be properly furnished with a bed, appropriate and adequate bedding, nightstand, and sufficient lighting.

BATHROOMS: There is one (1) bathroom for resident use. Bathroom was observed to be equipped with nonskid surfaces and grab bars. The LPA observed bathroom to be clean, properly supplied and had functional fixtures. Starting at 1:57pm., the water temperature was measured in the bathroom, and it measured 106.5 degrees Fahrenheit.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

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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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: 01/13/2025

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Report Continued from LIC 809...

COMMON AREAS: The LPA observed the living room and dining room area to be furnished appropriately and all furniture was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. The LPA observed required postings throughout the common space. There is a working telephone on premises. No obstructions or hazards were observed inside or out. Emergency disaster drills are conducted quarterly, with the last one being a fire drill on 11/15/2024.

OUTDOOR / BACKYARD: There is a shaded area in the backyard with appropriate furniture for resident use. The exterior passageways were clean and clear of any obstructions. The LPA observed one (1) self-latching gate for emergency use. No bodies of water noted at the time of the visit.

GARAGE: The LPA observed a refrigerator with additional food inside the garage. Washer and dryer were also observed. Staff assist resident with all laundry needs. Detergents and cleaning solutions were observed in a locked cabinet at the time of the visit. The LPA observed an adequate supply of emergency food and water.

RECORD REVIEW: The LPA reviewed one (1) Resident Record and two (2) Personnel Records including the current Administrator’s file starting at 12:55pm.

Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, and current needs and services plan/IPP. All files were complete.

Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR certifications, and adequate training. All records were in order.

Administrator’s Certificate is active until 08/23/2025.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

LIC809 (FAS) - (06/04)

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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: 01/13/2025

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Report Continued from LIC 809C...

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2-i home.

MEDICATION REVIEW: The LPA conducted a medication review at approximately 2:30pm. Medications are centrally stored in a locked box in the kitchen. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appeared to be given as prescribed at the time of the visit.

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

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 01/13/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 01/13/2025

LIC809 (FAS) - (06/04)

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