565800253-9-22-2023-29-AS-MARO-CVWS7N-20230922133750

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800253
Report Date: 09/22/2023
Date Signed: 09/22/2023 01:37:58 PM

Document Has Been Signed on 09/22/2023 01:37 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:	ASSOCIATION FOR RETARDED CITIZENS - VENTURA		FACILITY NUMBER:	565800253
ADMINISTRATOR:	MITCHEL GARCIA		FACILITY TYPE:	775
ADDRESS:	3340 E. LOS ANGELES AVENUE		TELEPHONE:	(805) 527-1358
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 90		CENSUS: 33	DATE:	09/22/2023
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME BEGAN:	08:00 AM
MET WITH:	Mitchel Garcia		TIME COMPLETED:	01:45 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) Martha Arroyo arrived at the facility unannounced for a required one-year annual inspection today at 8:00 a.m. The last annual conducted at this facility was on 09/14/2022. Upon arrival, the LPA met with Case Manager, Ashleigh Chenault and the reason for the visit was explained. The Program Manager, Mitchel Garcia arrived shortly after. Entrance interview conducted. At 8:13 a.m., the LPA toured the physical plant to ensure there are no health and safety hazards and facility is in compliance with Title 22 Regulations. The following was noted during the plant tour: The day program operates from 8:00 a.m. to 4:30 p.m. The day program is currently staffed appropriately with the necessary staff to consumer ratios. The facility has seven (7) activity rooms, nine (9) participant bathrooms, two (2) outdoor areas, a breakroom/staff room, and a kitchen area. Common Areas: At 8:55 a.m., the LPA observed the kitchen area to be clean and in good condition at the time of visit. The refrigerator was observed with participants lunches and snacks. There are several fire extinguishers throughout the facility; they all were fully charged and were last serviced 11/22/2022. Carbon monoxide detectors are wired and operational at the time of the visit. The last fire inspection was completed on 06/14/2023 and was found to be in compliance with Fire Code Regulations at the time of inspection. Fire and earthquake drills conducted within the last 6 months as per regulation; the last one conducted 09/15/2023. Facility temperature is kept at 74 degrees Fahrenheit. No bodies of water noted at the time of the visit. Activities are both designed for both as individuals and as a group. The LPA observed staff interacting with participants during time of visit. No obstructions or hazards were observed inside or out. Equipment used for activities was in good condition at the time of the visit. Washer and dryer observed on premises locked and inaccessible to participants. (Report Continued on LIC 809C...)

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

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 4

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: ASSOCIATION FOR RETARDED CITIZENS - VENTURA	FACILITY NUMBER: 565800253
	VISIT DATE: 09/22/2023

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
26
27
28
29
30
31
32

(Report Continued from LIC 809...)

Bathrooms: The LPA inspected nine (9) restrooms. Restrooms were clean and trash cans have lids to protect clients from cross contamination. The bathrooms were sufficiently stocked with soap and paper towels. The hot water temperature was measured in all participant bathrooms, and they measured between 105- and 120-degrees Fahrenheit at the time of the visit.

File Review: Records review began at 9:16 a.m.; five (5) participant records were reviewed for the following: signed admission agreements, current medical assessments with TB results, Consent for Treatment form, Individual Program Plans (IPP), and current needs and services plan. All participant records were in order. The LPA reviewed four (4) staff files for, but not limited to, the following: personnel records, health screening, criminal record statements, and valid first aid/CPR. Training records on file. All staff records were in order.

Medications: Medications review began at 10:55 a.m. Medications are centrally stored and locked inside the medication room. All medications including PRNs were labeled, stored and locked inaccessible to participants. PRNs have physicians order on file. Medications are labeled and checked for expiration dates. No errors found during medication audit.

The LPA obtained the following documents at the time of visit: LIC500 Personnel Report and Client Roster.

No deficiencies issued at this time. Exit interview conducted. The report was reviewed, and a copy was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 09/22/2023

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

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/22/2023

LIC809 (FAS) - (06/04)

Page: 2 of 4