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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800686
Report Date: 08/23/2023
Date Signed: 08/23/2023 04:27:08 PM


Document Has Been Signed on 08/23/2023 04:27 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:ST. PAUL'S HOME CARE IIFACILITY NUMBER:
565800686
ADMINISTRATOR:NORMA ZANDERSFACILITY TYPE:
740
ADDRESS:1431 CROCKER STREETTELEPHONE:
(805) 638-6004
CITY:SIMI VALLEYSTATE: CAZIP CODE:
93065
CAPACITY:6CENSUS: 4DATE:
08/23/2023
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
01:45 PM
MET WITH:Norma ZandersTIME COMPLETED:
04:30 PM
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Licensing Program Analyst (LPA) Zabel Chochian conducted an unannounced Required 1-Year visit to the above facility. Upon arrival LPA was greeted by staff. Staff contacted Administrator Norma Zandars who arrived shortly after LPA.

Upon arrival a physical plant tour was conducted for compliance with safety, maintenance and operational requirements. The facility has six (6) bedrooms and three (3) bathrooms. Smoke detectors and Carbon Monoxide detector were tested and function properly. Fire extinguisher located in kitchen area observed operable with last service date of 09/21/2022. Kitchen: The kitchen appeared clean and the appliances and fixtures functional. LPA observed a sufficient amount of perishable and non-perishable food at the facility; properly stored. Sharp objects are stored in locked kitchen cabinet. Bedrooms: The resident bedrooms were properly furnished with at least one chair, night stand and sufficient lighting for each resident; appropriate and adequate bedding and linens such as sheets, pillowcases, mattress pads, and blankets. Bathrooms: LPA observed all bathrooms were clean, properly supplied and had functional fixtures. LPA observed grab bars and non-skid mats in all bathrooms. Sufficient amounts of supplies for personal hygiene observed. Hot water temperature measured within required range (105-120*f). Common Areas: These included the living room and dining area. The common areas were checked for cleanliness and furniture was checked for functionality. Surrounding Grounds (Outdoors): Surroundings observed clean and hazard free; a shaded area with furniture for outdoor use observed.
Staff and resident records: (2:30pm) Staff have current first aid and training documentation showing required training completed. Resident records observed complete. All residents have a current annual physician report, current assessment and admission agreement on file. Last disaster drills conducted in 03/1/2023. First aid kit observed to be complete with all required item. Medications: (3:15pm) Medications are stored in a locked cabinet in the kitchen. Medications observed labeled and recorded accordingly. Facility observed to be in substantial compliance. Exit interview conducted. Copy of report issues.
SUPERVISOR'S NAME: Desaree PereraTELEPHONE: (818) 596-4347
LICENSING EVALUATOR NAME: Zabel ChochianTELEPHONE: (818) 419-5440
LICENSING EVALUATOR SIGNATURE:
DATE: 08/23/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 08/23/2023
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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