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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800673
Report Date: 05/12/2023
Date Signed: 05/12/2023 01:21:20 PM


Document Has Been Signed on 05/12/2023 01:21 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:CACCAM'S SORREL RESIDENCEFACILITY NUMBER:
565800673
ADMINISTRATOR:VENIS CACCAMFACILITY TYPE:
740
ADDRESS:1325 SORREL STREETTELEPHONE:
(805) 522-9510
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:5CENSUS: 5DATE:
05/12/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:29 AM
MET WITH:Venis CaccamTIME COMPLETED:
01:15 PM
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Licensing Program Analyst (LPA) Zabel Chochian arrived unannounced to conduct a required annual visit. LPA was greeted by staff. LPA introduced self and reason for visit was explained. Present during todays visit were one staff and one client; four clients were attending Day Program. Administrator Venis Caccam was contacted and informed of the visit. Between 9:45am-10:25am, LPA and staff toured the physical plant areas inside and outside from to ensure there are no health and safety hazards and community is in compliance with Title 22 Regulations. KITCHEN: Knives and sharp objects are stored in a locked cabinet in the kitchen. Cleaning supplies are stored locked and inaccessible to residents in the garage. Kitchen appliances were in operable condition. The facility has a sufficient supply of perishable and non-perishable food. BEDROOMS: Resident bedrooms were furnished appropriately with clean linens, appropriate furnishings and sufficient lighting. RESTROOMS: Resident restrooms are clean and sanitary and in operating condition with grab bars and non-skid surfaces. Bathrooms were fully stocked with soap and paper towels. Appropriate hand-washing signs were observed in all bathrooms. Hot water temperature measured at 110 degrees Fahrenheit. COMMON SPACES: Living room and dining room furniture was observed to be in good condition. There is a fireplace in the dining room, which is inoperable. The LPA observed the required licensing postings listed throughout the facility. The washer and dryer were in the hallway and access to the appliances are kept locked and inaccessible to residents. Surrounding Grounds (Outdoors): There is a shaded area with furniture for residents use. Exits/entrance areas observed clear no obstruction. Smoke/carbon monoxide detectors checked and were operable during today's visit. Fire extinguisher date serviced 4/2023.

File review was conducted from 10:30am-11:45am: All residents files were reviewed for required records and completeness with all required documentation such as Admission Agreements, P&I monies/records, Physicians reports, Appraisal/Needs and services plan. Staff files reviewed included Criminal Record clearance, current first aid, health screening/TB and training. At approximately 11:45am - 12pm, Disaster drill records reviewed with Ms. Caccam. Last disaster drills conducted in 4/6/2023. Medication stored in locked cabinet in the living/dining area. Medication procedure/records were reviewed with staff and Ms. Caccam at approximately 12pm; found no discrepancies. Licensee is in compliance with the California Code of Regulations, Title 22, Division 6, Chapter 8. Exit interview held, copy of report provided.

SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 05/12/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/12/2023
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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