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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800405
Report Date: 09/25/2023
Date Signed: 09/25/2023 06:26:32 PM


Document Has Been Signed on 09/25/2023 06:26 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 IFACILITY NUMBER:
565800405
ADMINISTRATOR:MARIA V. PASILABANFACILITY TYPE:
740
ADDRESS:2585 LOWELL COURTTELEPHONE:
(805) 582-1877
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 3DATE:
09/25/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Maria Mendez & Maria V. PasilabanTIME COMPLETED:
05:00 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived at the facility to conduct a required annual visit. Upon arrival LPA met with staff. Staff contacted Licensee Maria Mendez. Reason for visit was explained. Mrs. Mendez arrived to the facility shortly after LPA.

At approximately 2pm, LPA and staff toured the physical plant areas inside and outside to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The carbon monoxide and smoke detectors were tested and all functioned properly. The fire extinguisher appeared fully charged and was last inspected 7/12/2023. KITCHEN: Knives were stored in a locked drawer and cleaning supplies were stored in the locked garage. Kitchen appliances appeared to be in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: The LPA observed one staff bedroom, two double-occupancy client bedrooms and two single-occupancy client bedrooms which were furnished appropriately. RESTROOMS: Restrooms are clean and sanitary and in operating condition. Hot water measured at 113*f. COMMON SPACES: At the time of the visit, living room and dining room furniture was observed to be in good condition. The LPA observed the required postings throughout the facility. The backyard patio is equipped with furniture for clients' use.


RESIDENT and STAFF FILES: reviewed at approximately 3pm. Resident files were observed to be complete with current reappraisals, physicians reports, admission agreements and other required documentation. Staff files were also observed to be current with all required documents such as criminal record clearances, health screenings, current first aid training and on going required annual training. A discussion was held with Licensee Maria Mendez of the requirement that the licensee shall maintain documentation of each person who provides training to staff; name, address and telephone number. Also the training record shall included but not limited to training times, date, and hours of training provided. MEDICATIONS: reviewed at 4pm; medications are stored in locked cabinet located in the kitchen; record of residents medication are kept; records observed to be accurate with medication on hand.
No deficiencies observed. Exit interview conducted. Copy of report provided.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 09/25/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/25/2023
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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