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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 565800867
Report Date: 01/19/2024
Date Signed: 01/19/2024 11:49:28 AM

Document Has Been Signed on 01/19/2024 11:49 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364
FACILITY NAME:ARC-HERITAGE VALLEYFACILITY NUMBER:
565800867
ADMINISTRATOR:SONIA SALINASFACILITY TYPE:
775
ADDRESS:116 NORTH 10TH STREETTELEPHONE:
(805) 933-9029
CITY:SANTA PAULASTATE: CAZIP CODE:
93060
CAPACITY: 90CENSUS: 40DATE:
01/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:00 AM
MET WITH:Katie GomezTIME COMPLETED:
11:55 AM
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Licensing Program Analyst (LPA) Teresa Camara conducted a required annual visit at 9:00 a.m. The LPA met with Administrative Kathleen "Katie" Gomez and explained the reason for the visit.

The LPA toured the physical plant areas to ensure there are no health and safety hazards and the facility is in compliance with Title 22 Regulations. The fire extinguishers were last serviced on 6/20/2023 and appeared fully charged. The carbon monoxide detector and smoke detectors were tested and functioned properly.

KITCHEN: The kitchen area is kept clean and locked. Dish soap and other toxins are stored away from food and drinking water. Clients bring their own lunch but the facility offers snacks for clients.

RESTROOMS: Restrooms (three) are clean and sanitary and in operating condition.

CHANGING ROOM: The changing room had a supply of hygiene products, a bed with protective paper that is changed between clients and a hoyer lift if needed. This room is used as an isolation room if necessary.

COMMON SPACES: Furnishings were observed to be in good condition. The facility has two large activity spaces, a dining room and a sensory room. The LPA observed the required postings throughout the facility as well as the monthly activity schedule.

RECORDS: LPA reviewed five client files and five staff files; all were complete. All staff are fingerprint cleared and associated to the facility. The facility disaster plan is also complete and the facility conducts evacuation drills monthly. The centrally stored medication and destruction logs and medications were reviewed at 11:00 a.m. and medications appear to be given as prescribed.

INTERVIEWS: LPA interviewed three clients and two staff; there were no concerns.

No deficiencies observed. Exit interview conducted and report issued.

SUPERVISORS NAME: Desaree Perera
LICENSING EVALUATOR NAME: Teresa Camara
LICENSING EVALUATOR SIGNATURE: DATE: 01/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 01/19/2024
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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