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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800253
Report Date: 05/02/2024
Date Signed: 05/02/2024 03:02:07 PM

Document Has Been Signed on 05/02/2024 03:02 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 - VENTURAFACILITY NUMBER:
565800253
ADMINISTRATOR/
DIRECTOR:		MITCHEL GARCIAFACILITY TYPE:
775
ADDRESS:3340 E. LOS ANGELES AVENUETELEPHONE:
(805) 527-1358
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 90CENSUS: 21DATE:
05/02/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:55 PM
MET WITH:Mitchel Garcia / Ashleigh ChenaultTIME VISIT/
INSPECTION COMPLETED:
03:00 PM
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Licensing Program Analyst (LPA)s Brian Balisi and Martha Arroyo  conducted an unannounced case management visit in regard to a self reported incidents that occurred on 04/02/2024 and 04/20/2024. On 04/02/2024, it was reported, Participant #1(P1) did not receive a beverage while attending the program. On 04/20/2024, Participant #2 (P2), digested a small amount of non-toxic paint while under staff supervision. LPA's met with Program Manager Mitchel Garcia and explained the reason for the visit.

Between 12:55pm – 03:00pm, LPA's  conducted a physical plant, interviewed staff and reviewed and obtained copies of pertinent documents relevant to the incident. LPA's did not observe any immediate or potential health and safety concerns at this time.

LPA's have determined further investigation is needed and will return at a later date to complete the investigation if warranted.

Exit interview conducted and copy of report issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Brian Balisi
LICENSING EVALUATOR SIGNATURE: DATE: 05/02/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 05/02/2024
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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