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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800113
Report Date: 10/23/2023
Date Signed: 10/23/2023 06:18:10 PM


Document Has Been Signed on 10/23/2023 06:18 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 IIIFACILITY NUMBER:
565800113
ADMINISTRATOR:WALTER AND MARIA MENDEZFACILITY TYPE:
740
ADDRESS:2522 GRAYSTONE PLACETELEPHONE:
(805) 522-7274
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 5DATE:
10/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
10:00 AM
MET WITH:Maria Mendez & Christopher FulgentesTIME COMPLETED:
02:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted a Required Annual visit to the above facility. LPA was greeted by staff . Licensee Maria Mendez arrived shortly after and reason for the visit was explained.

A tour of the physical plant was conducted for compliance with safety, maintenance and operational requirements from 10am-10:45am. The facility has six (6) bedrooms and three (3) bathrooms for residents use. Currently five (5) residents rooms are occupied. There is an additional bedroom designated for staff use. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident. The bedrooms had appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Residents have sufficient amounts of supplies for personal hygiene. Hot water temperature measured at 107 degrees Fahrenheit. Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of (2-day) perishable and (7-day) non-perishable food at the facility. Sharp objects are stored in a lock box in the kitchen. Garage is attached to the home with and entrance off the Kitchen/dining area. Laundry machines and supplies are stored in the garage inaccessible to residents. Surrounding Grounds (Outdoors): There is a shaded area with furniture for outdoor use. Smoke and Carbon Monoxide detector tested and function properly. Fire extingisher last serviced 7/12/2023. Resident file review (11am-12pm): All residents have an annual physician report; Needs and Service plan; admission agreement and all required records per Title 22 on file. Medications/medication documentation reviewed at approximately 12pm-1pm. Centrally stored and medication administration records reviewed. First aid kit is complete. Staff file review (1pm-2pm) Staff have current first aid and required training completed. All required personnel records observed on file.
Exit Interview Conducted / Appeal Rights Discussed / A Copy of the Report Issued.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 10/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 10/23/2023
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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