565800182-12-9-2022-29-AS-EPEI-CLXUTX-20221209145241

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800182
Report Date: 12/09/2022
Date Signed: 12/09/2022 02:53:06 PM

Document Has Been Signed on 12/09/2022 02:53 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:	ST. PAUL'S R.C.F.E.		FACILITY NUMBER:	565800182
ADMINISTRATOR:	MALARI MARILOU		FACILITY TYPE:	740
ADDRESS:	2292 GODDARD AVE		TELEPHONE:	(805) 581-9457
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY:	5	CENSUS: 4	DATE:	12/09/2022
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	01:25 PM
MET WITH:	Marilou Malari, Administrator		TIME COMPLETED:	03:00 PM

NARRATIVE
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25	Licensing Program Analyst (LPA) Emily Peraldi arrived at the facility unannounced to conduct a required annual visit. At 1:25 p.m., the LPA was greeted by staff. At 1:35 p.m., the Administrator arrived at the facility. This annual had a specific emphasis on infection control practices and procedures. At 1:48 p.m., the LPA, along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that the facility is in compliance with Title 22 Regulations. KITCHEN: The LPA observed the kitchen/dining area. Knives are stored in a locked kitchen cabinet. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. At 1:51 p.m., hot water measured at 105.1-degree Fahrenheit. Medications are located in a locked cabinet near the kitchen. BEDROOMS: The LPA observed resident bedrooms, which were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. Inside temperature was maintained at a comfortable level. The upstairs portion of the house is for staff living quarters. RESTROOMS: Restrooms are relatively clean and sanitary and in operating condition with grab bars and non-skid mats. At 2:45 p.m., hot water measured at 105.0-degree Fahrenheit. The sinks had sufficient liquid soap, and paper towels. OUTDOOR SPACE: At 1:52 p.m., the LPA observed the back patio which has a covered outdoor area for resident use. Passageways were free and clear from obstruction. Continued on LIC 809-C.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022

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: ST. PAUL'S R.C.F.E.	FACILITY NUMBER: 565800182
	VISIT DATE: 12/09/2022

NARRATIVE

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COMMON AREA: The LPA observed common area to be relatively clean and properly furnished. The LPA observed the fire extinguisher to be fully charged and last serviced on 09/19/2022. Signs are posted throughout facility to promote handwashing, and cough/sneeze etiquette. At 2:03 p.m., fire alarms/carbon monoxide detectors were tested and functioned properly.

GARAGE: The garage is attached to the house. Laundry units are located inside the garage. Cleaning solutions, toxins, chemicals and hazardous items were inaccessible and locked away in the garage.

INFECTION CONTROL: During today’s visit, the LPA spoke with the Administrator regarding the facility’s infection control practices. The LPA observed a 30-day supply of Personal Protection Equipment (PPE) and the facility is able to obtain additional supplies as needed. The facility’s cleaning protocol is sufficient. The facility’s policies and procedures as it pertains to infection control are adequate.

No deficiencies were observed at this time. Exit interview conducted and report issued, and a copy of the report was provided via email.

SUPERVISOR'S NAME: Kristin Heffernan	TELEPHONE: (818) 593-4493
LICENSING EVALUATOR NAME: Emily Peraldi	TELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:	DATE: 12/09/2022

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 12/09/2022

LIC809 (FAS) - (06/04)

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