565800712-2-18-2025-29-AS-MARO-DDZTWY-20250218140618

Community Care Licensing

FACILITY EVALUATION REPORT

Facility Number: 565800712
Report Date: 02/18/2025
Date Signed: 02/18/2025 02:07:13 PM

Document Has Been Signed on 02/18/2025 02:07 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:	SORIAN'S CARE HOME		FACILITY NUMBER:	565800712
ADMINISTRATOR/ DIRECTOR:	SARA SORIANO		FACILITY TYPE:	735
ADDRESS:	5464 KATHERINE ST.		TELEPHONE:	(805) 527-0524
CITY:	SIMI VALLEY	STATE: CA	ZIP CODE:	93063
CAPACITY: 4		CENSUS: 4	DATE:	02/18/2025
TYPE OF VISIT:	Required - 1 Year	UNANNOUNCED	TIME VISIT/ INSPECTION BEGAN:	09:25 AM
MET WITH:	Jerson Soriano		TIME VISIT/ INSPECTION COMPLETED:	02:15 PM

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Licensing Program Analyst (LPA) Martha Arroyo arrived at the facility unannounced to conduct a required annual visit today at 9:25am. Upon arrival, the LPA was greeted by the Administrator, Jerson Soriano and at this time, the reason for the visit was explained. During the inspection, three residents were at day program and one resident out visiting family. Entrance interview conducted.

Starting at 9:42am, the LPA along with the Administrator toured the physical plant areas inside and outside to ensure there are no health and safety hazards and that facility is in compliance with Title 22 Regulations. The following was observed:

KITCHEN: The LPA observed the kitchen/food area at approximately 9:54am. The kitchen appliances appeared to be clean and in operable condition. The facility has a sufficient supply of seven (7) days non-perishable and two (2) days perishable food; properly stored. Refrigerator and dry food pantry were checked for proper labels and expiration dates. Knives and sharps were observed in a locked drawer inaccessible to residents in care. Cleaning supplies were observed under the kitchen sink locked and inaccessible. At 9:50am, the kitchen sink was measured for hot water temperature, and it measured 105. 8 degrees Fahrenheit.

BEDROOMS: There are four (4) bedrooms for resident use and one (1) bedroom designated for staff only. The LPA observed all resident bedrooms to be properly furnished with a bed, appropriate and adequate bedding, nightstand, and sufficient lighting. There is a closet in the hallway with additional clean linens and towels for resident use. Personal hygiene items were observed locked in a hallway closet at the time of the visit.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

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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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: SORIAN'S CARE HOME	FACILITY NUMBER: 565800712
	VISIT DATE: 02/18/2025

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Report Continued from LIC 809...

BATHROOMS: There are two (2) bathrooms for resident use. Bathrooms were observed to be equipped with nonskid surfaces and grab bars. The LPA observed bathrooms to be clean, properly supplied and had functional fixtures. Hand washing signs were observed posted at the time of the visit. Starting at 9:44am., the water temperature was measured in bathrooms, and they measured within the required range of 105 to 120 degrees Fahrenheit.

COMMON AREAS: The LPA observed the living room and dining room area to be furnished appropriately and all furniture was observed to be in good condition at the time of the visit. The facility maintained a comfortable temperature. The LPA observed required postings throughout the common space. There is a working telephone on premises. Facility has an adequate amount of emergency food and water. At 10:03am, smoke detector(s) and carbon monoxide detector were tested and were operational at the time of the visit. The LPA observed cameras in common areas and outside perimeter. No obstructions or hazards were observed inside or out.

GARAGE: The garage is attached to the facility. There is one (1) additional freezer with perishable items in good condition. The washer and dryer were observed inside the garage. The LPA observed detergents and cleaning supplies in a locked cabinet at the time of the visit. The LPA observed a sufficient supply of Personal Protection Equipment (PPE).

OUTDOOR / BACKYARD: There is a shaded area in the backyard with appropriate furniture for resident use. The exterior passageways were clean and clear of any obstructions at the time of the visit. The LPA observed one (1) self-latching gate for emergency use. There is a pool that was observed to be locked and inaccessible at the time of the visit.

RECORD REVIEW: The LPA reviewed four (4) Resident Records and three (3) Personnel Records including the Administrator’s file starting at 10:15am.

Report Continued on LIC 809C...

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

LIC809 (FAS) - (06/04)

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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: SORIAN'S CARE HOME	FACILITY NUMBER: 565800712
	VISIT DATE: 02/18/2025

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Report Continued from LIC 809C...

Resident files were reviewed for, but not limited to, the following: signed admission agreements, current medical assessments with TB results, LIC627(c) Consent for Treatment form, and current needs and services plan/IPP. All files were complete.

Personnel files were reviewed for, but not limited to: personnel records, health assessments, criminal record clearances, first aid/CPR certifications, and yearly training. All records were in order.

Administrator’s Certificate is active until 09/15/2026.

The facility is vendored by Tri-Counties Regional Center (TCRC) as a level 2 home.

During today’s visit, the LPA conducted an interview with one (1) staff.

INFECTION CONTROL/EMERGENCY DISASTER PLANNING: During today’s visit, the LPA reviewed the facility's infection control practices and the facility's emergency disaster plan. The facility’s policies and procedures as it pertains to infection control are adequate. The facility has two (2) generators in case of an emergency. Fire extinguisher was observed to be fully charged on 12/30/2024. Emergency disaster drills are conducted quarterly; last earthquake drill conducted on 01/15/2025 and fire drill was conducted on 01/16/2025.

MEDICATION REVIEW: The LPA conducted a medication review at approximately 12:20pm. Medications are centrally stored in a locked cabinet adjacent to the living room. All medications including PRNs were labeled, stored, and locked inaccessible to residents in care. Medications appear to be given as prescribed at the time of the visit.

No citations issued. Exit interview conducted. Report was reviewed and a copy was provided.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Martha Arroyo
LICENSING EVALUATOR SIGNATURE:	DATE: 02/18/2025

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 02/18/2025

LIC809 (FAS) - (06/04)

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