565800113-10-15-2024-29-AS-MARO-DA3UB3-20241015152540

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800113
Report Date: 10/15/2024
Date Signed: 10/15/2024 03:25:46 PM

Document Has Been Signed on 10/15/2024 03:25 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:	SIMI VALLEY RESIDENTIAL CARE III		FACILITY NUMBER:	565800113
ADMINISTRATOR:	WALTER AND MARIA MENDEZ		FACILITY TYPE:	740
ADDRESS:	2522 GRAYSTONE PLACE		TELEPHONE:	(805) 522-7274
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93065
CAPACITY:	6	CENSUS: 5	DATE:	10/15/2024
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	10:45 AM
MET WITH:	Maria Mendez		TIME COMPLETED:	03:30 PM

NARRATIVE

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today. The last annual inspection conducted at this facility was on 10/23/2023. Upon arrival, there were two (2) staff and five (5) residents present. The LPA was greeted by facility staff who contacted the Licensee Representative via telephone. The Licensee Representative, Maria Mendez arrived during the inspection. Entrance interview conducted.

At 10:58am, the LPA along with staff 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 following was observed:

KITCHEN: The LPA inspected the kitchen area at 11:02am. Knives and sharps were observed in a locked box inaccessible to residents in care. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food; properly stored. Refrigerator and food pantry were checked for proper labels and expiration dates.

COMMON AREAS: The living room and dining room areas were furnished appropriately and furniture appeared to be in good condition at the time of the visit. The facility maintained a comfortable temperature. LPA observed required postings throughout the common space. Activities for resident use were observed in the living room. There is a working telephone on premises.

REPORT CONTINUED ON LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (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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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: SIMI VALLEY RESIDENTIAL CARE III	FACILITY NUMBER: 565800113
	VISIT DATE: 10/15/2024

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REPORT CONTINUED FROM LIC 809...

RESTROOMS: There are three (3) restrooms for resident use. Restrooms were observed clean and in sanitary condition with grab bars and non-skid surfaces. The bathrooms were sufficiently stocked with supplies and paper towels. Hand washing signs were observed posted in the restrooms. LPA observed trash cans with tight fitting lids in all bathrooms. The hot water temperature was measured in all bathrooms; the first bathroom measured108.6 degrees Fahrenheit at 11:11am; the second bathroom measured 110.4 degrees Fahrenheit at 11:16am; and the third bathroom measured 111.2 degrees Fahrenheit at 11:20am.

BEDROOMS: There are six (6) bedrooms for resident use; all of which are designated for single occupancy. All resident rooms were observed to be furnished appropriately and had sufficient lighting. Additional clean linens, towels, and washcloths were observed accessible to residents in care. Staff bedroom observed on premises.

GARAGE: The garage is maintained inaccessible to residents in care. LPA observed an additional refrigerator with food in good condition. There is a washer and dryer inside the garage. Cleaning supplies, detergents, and toxins were observed locked and inaccessible to residents in care. Facility has an adequate amount of emergency food and water.

BACKYARD: The backyard has a covered patio area with adequate furniture for resident use. The exterior passageways were clean and clear of any obstructions at the time of the visit. LPA observed two (2) self-latching gates for emergency use. There were no bodies of water noted at the time of the visit.

RECORDS: LPA reviewed Resident Records at 11:33am and Personnel Records at 12:35pm.

REPORT CONTINUED ON LIC 809C...

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (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

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: SIMI VALLEY RESIDENTIAL CARE III	FACILITY NUMBER: 565800113
	VISIT DATE: 10/15/2024

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REPORT CONTINUED FROM LIC 809C...

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. Records were in order.

Three (3) personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid / CPR training, and the appropriate training. All files were complete. Administrator Certificate is valid until 06/30/2025.

During today’s visit, LPA conducted interviews with three (3) residents and one (1) staff member.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today's visit, LPA reviewed the facility's infection control policy as well as the emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. At 11:22am, the smoke detectors and carbon monoxide detector were tested and operational at the time of the visit. Fire extinguisher was observed fully charged with a date of 8/09/2024. Emergency disaster drills conducted quarterly as per regulation; the last fire drill was conducted on 10/01/2024.

MEDICATIONS: Medications review began at approximately 1:10pm. Medications are stored in locked cabinets adjacent to the living room inaccessible to residents in care. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. PRN authorization letters on file for each resident. Medications appeared to be given as prescribed at the time of the visit.

No citations issued at this time. Exit interview conducted. Report was reviewed and a copy issued.

SUPERVISOR'S NAME: Desaree Perera	TELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Martha Arroyo	TELEPHONE: (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

LIC809 (FAS) - (06/04)

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