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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800299
Report Date: 04/14/2023
Date Signed: 04/14/2023 04:47:19 PM


COMPREHENSIVE INSPECTION

Document Has Been Signed on 04/14/2023 04:47 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:CENTURY HOME CARE FOR THE ELDERLYFACILITY NUMBER:
565800299
ADMINISTRATOR:NORBERTO V. LAIGOFACILITY TYPE:
740
ADDRESS:2353 CENTURY AVENUETELEPHONE:
(805) 579-6067
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93063
CAPACITY: 6CENSUS: 4DATE:
04/14/2023
TYPE OF VISIT:Annual/RandomUNANNOUNCEDTIME BEGAN:
02:20 PM
MET WITH:Norberto LaigoTIME COMPLETED:
04:50 PM
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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct an Annual/Random visit. Upon arrival, the LPA met with the Administrator and explained the reason for the visit. Entrance interview conducted.

At 2:35 p.m., the LPA 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 and sharps are stored locked under the kitchen sink. Kitchen appliances are in operable condition. The facility has a sufficient supply of perishable and non-perishable food. Medications and first aid kits are located in a locked file cabinet adjacent to 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.

RESTROOMS: Restrooms were observed clean and sanitary and in operating condition with grab bars and non-skid mats. The hot water temperature was measured and in compliance between 105- and 120-degrees Fahrenheit at the time of the visit.

COMMON AREAS/OUTDOOR SPACE: The LPA observed the common area to be clean and properly furnished. The LPA observed the fire extinguisher to be fully charged. The LPA observed the back patio which has a covered outdoor area for resident use. There is a self-latching gate on the side of the house designated for an emergency exit. There were no bodies of water at the time of visit.

Exit interview conducted. No citations issued. A copy of the report was issued.
SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE: DATE: 04/14/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 04/14/2023
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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