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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800417
Report Date: 09/21/2021
Date Signed: 09/21/2021 06:21:26 PM

Document Has Been Signed on 09/21/2021 06:21 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 IVFACILITY NUMBER:
565800417
ADMINISTRATOR:MARIA MENDEZFACILITY TYPE:
740
ADDRESS:2378 E. KENTFIELD STREETTELEPHONE:
(805) 583-3182
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY: 6CENSUS: 2DATE:
09/21/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:00 AM
MET WITH:Maria MendezTIME COMPLETED:
04:53 PM
NARRATIVE
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Licensing Program Analysts (LPA's) JoAnn Rosales and Teresa Camara conducted an unannounced Required -1 Year inspection. LPA's met with Administrator Maria Mendez.

Today's evaluation included but was not limited to: building and grounds, resident rooms, bathrooms, hot water temperature (read at 105.2 degrees F) in common resident bathroom, common areas, personal accommodations, food and first aid supplies. LPA observed lamps/lights as well as sufficient furnishings and linens for each room. LPA observed fire extinguisher fully charged. Centrally stored medicines are kept in a cabinet just outside the kitchen. Hygiene items are being provided. Grab bars and non-skid materials were present in the bathrooms. LPA observed facility to be a comfortable temperature throughout the visit. Smoke alarms and carbon monoxide detectors were tested and were operable at the time of the visit. Indoor and outdoor area toured passageways were free from obstruction. LPA reviewed resident records and medications. LPA reviewed staff records. During facility tour LPA observed one central entry point designated for universal entry screening. Cleaning supplies were observed and infection control practices were discussed.

During the facility tour on 9/21/21 at 11:30 am with the Administrator LPA observed resident #2 (R2's) ibuprofen in a kitchen drawer accessible to residents.

During the facility tour on 9/21/21 at 11:41 am with the Administrator LPA observed antacid tablets and menthol cough suppressant/oral anesthetic drops in R1's bedroom accessible to residents.

During a review of resident medications on 9/21/21 starting at 1:42 pm with the Administrator LPA observed that R1 is prescribed Melatonin 3 mg 1 tablet at BT and is being given Melatonin 5 mg 1 tablet at BT.
Continued on 809C
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE: DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 09/21/2021
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: SIMI VALLEY RESIDENTIAL CARE IV
FACILITY NUMBER: 565800417
VISIT DATE: 09/21/2021
NARRATIVE
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Pursuant to Title 22 Division 6 Chapter 8 of the CA Code of Regulations, the following deficiencies were cited (refer to LIC 809-D):

Exit interview conducted, today's reports and appeal rights were reviewed and emailed to the Administrator.
SUPERVISORS NAME: Kristin Heffernan
LICENSING EVALUATOR NAME: Joann Rosales
LICENSING EVALUATOR SIGNATURE:

DATE: 09/21/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 09/21/2021
LIC809 (FAS) - (06/04)
Page: 2 of 4
Document Has Been Signed on 09/21/2021 06:21 PM - It Cannot Be Edited


Created By: Joann Rosales On 09/21/2021 at 03:42 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMI VALLEY RESIDENTIAL CARE IV
FACILITY NUMBER: 565800417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Type A
Section Cited
CCR
87705(f)(2)
Care of Persons with Dementia
(f) The following shall be stored inaccessible to residents with dementia: (2) Over-the-counter medication, nutritional supplements or vitamins, alcohol, cigarettes, and toxic substances such as certain plants, gardening supplies, cleaning supplies and disinfectants.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on LPA's observation and record review, the licensee did not comply with the section cited above in 2 out of 12 medications for R1 and 1 out of 1 medications for R2 which poses an immediate health risk to persons in care.
POC Due Date: 09/22/2021
Plan of Correction
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Administrator placed medications in a locked medication cabinet during facility visit. Administrator stated that they will provide documentation of staff medication training to CCL by 10/1/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021


LIC809 (FAS) - (06/04)
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Document Has Been Signed on 09/21/2021 06:21 PM - It Cannot Be Edited


Created By: Joann Rosales On 09/21/2021 at 04:17 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364

FACILITY NAME: SIMI VALLEY RESIDENTIAL CARE IV
FACILITY NUMBER: 565800417

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 09/21/2021

DEFICIENCIES & PLANS OF CORRECTION (POCs)
Request Denied
Type A
Section Cited
CCR
87465(a)(5)
Incidental Medical and Dental Care Services
(5) The licensee shall assist residents with self-administered medications as needed.

This requirement is not met as evidenced by:
Deficient Practice Statement
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Based on medication review, the licensee did not comply with the section cited above in 1 out of 12 medications for R1 which poses an immediate health risk to persons in care.
POC Due Date: 09/22/2021
Plan of Correction
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Administrator stated that they will provide documentation of a new physicians order for R1's melatonin by 9/22/21. Administrator stated that they will provide documentation of staff medication training to CCL by 10/1/21.
Section Cited
Deficient Practice Statement
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POC Due Date:
Plan of Correction
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Kristin Heffernan
LICENSING EVALUATOR NAME:Joann Rosales
LICENSING EVALUATOR SIGNATURE:
DATE: 09/21/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/21/2021


LIC809 (FAS) - (06/04)
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